Mission Control | Andrew Jones of the Asheville Watchdog

Andrew Jones of the Asheville Watchdog is so busy covering Mission’s past, present and future, he has nine bylined stories about the hospital so far in February alone. I talked with him just yesterday to get the latest, including details of alarming findings from the US Centers for Medicare and Medicaid Services and the so-called Immediate Jeopardy Mission faces in potentially losing its ability to receive Medicare and Medicaid payments.

We talked about Mission’s formal plan of correction in response and why regulators approved a plan that many argue doesn’t address the root of the problems. We detail the stakes for Mission’s parent company, HCA, as a deadline for correction looms, and we look forward to what happens on both sides of whether regulators say Mission has effectively corrected what needs to be corrected.

00:31 The Plan of Correction and Staffing Issues
01:37 The Criticisms from Doctors, Nurses, and Officials
02:47 The Fine Line of Criticism and Cooperation
03:10 The Complex Relationship Between Hospitals and Governments
04:25 The Impact of the CMS Report
05:07 The Investigation and Its Implications
05:25 The Role of Traveling Nurses
07:00 The Timeline of HCA's Involvement
08:41 The Investigation of HCA by the Attorney General
11:20 The Immediate Jeopardy Status and Its Consequences
14:30 The Plan of Correction and Its Shortcomings
16:45 The Impact of Staffing Issues on Patient Care
21:02 The Future of Mission Hospital

SPONSOR: Make the most of your time this spring and turn over your housekeeping to Greenland Pro Cleaning. Use the code PODCAST at checkout for free bonus services.

SPONSOR: Satirical comedian Robert Dubac performs “Standup Jesus,” 8pm May 3-4 at the Wortham Center for the Performing Arts.

SPONSOR: Asheville City Soccer Club home games begin May 18 at Greenwood Field on the UNC-Asheville campus.

Transcript

Matt Peiken: Very apropos that you are just coming from a press conference. Tell me what were you just at and what was revealed? 

Andrew Jones: I just came from a press conference that was led by Senator Julie Mayfield, but was a sort of official announcement of a letter penned by several doctors, some of who your listeners may recognize Dr. Mike Massino, Dr. Clay Ballantyne, Dr. Bruce Kelly, Dr. Alan Lawlor and others. And they wrote a letter to the North Carolina department of health and human services on February 20th to say the plan of correction that Mission has implemented to fix some of the issues that were found through an investigation over there is not sufficient.

It's biggest gap, it's biggest missed opportunity, this plan of correction that Mission wrote, is hiring more full time nurses to run different units of the hospital, but especially the nursing department. 

Matt Peiken: It was interesting when I was reading through, you posted a PDF of a response to this plan of compliance, which I thought was obvious that a plan of compliance approval would be predicated on staffing. Why do you think, or what, why do these doctors and nurses believe that this plan was even approved by federal regulators where barely addressed staffing issues. 

Andrew Jones: You know these doctors and these advocates and Senator Mayfield and other local elected officials are walking a very fine line. I think what's important for them at this point is to work in concert with The State Department of Health and work in concert with the Centers for Medicare and Medicaid services to make sure that Mission comes into compliance.

But they also are pushing for the best possible scenario. And They are alleging that the way that the state and the federal government are going about asking Mission for changes is not the best possible scenario, essentially. There's a sense of criticism here saying the federal government and the state government needs to pressure Mission to do better. But there's also a sense of we want to come hand in hand with you. And as people in the community who are actually receiving the healthcare that this hospital gives, we think we have the best seat in the house to tell you what's absolutely necessary here.

And that's more staff. 

Matt Peiken: Why do you think it's a fine line? There's obviously some sharp criticisms here. There have been a lot of public blowback from whether it's Josh Stein, the state attorney general, Julie Mayfield, state senator, dozens and dozens of doctors, nurses, and staff who have been very sharply critical of HCA Mission.

Where is the walking on eggshells part of it coming in? 

Andrew Jones: So remember that this is a sensitive and tenuous relationship across the board. You have hospitals who are beholden to state and federal governments to follow state and federal regulations about how they run their systems.

You have state and federal governments who have to communicate and work with with those hospitals, not only to make sure they're in compliance, but also to make sure that they get the funding that they need to operate. You have local leaders who have relationships or connections both to the state and to the people who run the hospital.

And then you have patients who are at the receiving end of all of this care. And for all of that to work in concert, especially here in Asheville, people need to have good relationships and have good Diplomatic tactics, I think. But understand that the bulk of the criticism right now is aimed at HCA for allegedly mismanaging the way that care has been provided at Mission Health.

And I should say that it's no longer allegedly, because there's a federal document, 484 pages long, that says numerous people were injured as a result of deficiencies in care, and four people died. 

Matt Peiken: Yeah, this was the U. S. Centers for Medicare and Medicaid Services, the CMS report that you cited. I think you said it was 384 pages, this document, which I thought was interesting that, if you were to bullet point this, it laid out a litany of unsafe staffing levels, delays in care, lack of timely responses, unapproved and expired medications given to patients.

And that I thought was interesting that the CMS reviewed about 100 cases over 2022-23 and summarized 15. The letter that you cited that what the document you got said, that seemed like a paltry amount of cases to be reviewing, that there's way more that is beneath the surface here. 

Andrew Jones: Yeah. This is going to be a big discussion for I think years to come essentially is this investigation and I've been reporting on this investigation. Nurses have been calling me, when a surveyor walks into the building, they call me or they text me and they're like, they're here. 

Matt Peiken: That's great for a reporter to have that kind of trust.

Andrew Jones: I'm so thankful to my sources at Mission hospital. People who put their jobs on the risk to communicate with me because the hospital itself is not dedicated to transparency. So they call me and so in, October, November last year, even as early as September, I'm getting calls saying, there are people from the Joint Commission here. There are people from the state here. They are they are asking nurses to come into rooms. They're sitting down with them. They're asking them the most difficult questions they've ever been asked. They're reading charts.

I've heard first that they were pulling 40 patient charts. Then I heard they were pulling 70 patient charts. Now we know that they pulled nearly 100 charts. And the contention, as you just said, is that What if, and I'm posing this as a what if question, that's very important. What if this only scrapes the surface about deficiencies in care since the HCA takeover in 2020?

And there are people saying yes, that is the case. There is a lot more that needs to be looked at here. And everybody should be paying attention to that. Now whether or not that will lead to another set of investigations or whether the state and the federal government feel that this is just an appropriate stopping point is definitely a question.

But I think I can guarantee you something from my reporting. We have not seen this level of governmental accountability for Mission Hospital in Asheville since the HCA purchase in 2020. 

Matt Peiken: Let's back up a second because it took years for HCA to even be held to any account.

Please correct me if I'm wrong in this very quick timeline, but people right from the get go were scrutinizing this purchase. That from even before the deal closed, people saw a lot of red flags here. None of them were acted upon. That once the deal went through, all these changes happened that immediately resulted in people complaining about the levels of care, nothing was being done.

Finally, the state attorney general gets involved. Now mind you, he could have involved himself at the very onset of the deal. He has said, I had no power to stand in the way of this deal happening. I question that. And even the terms of the deal that were made, nothing was set in stone or on paper that compelled HCA to any standard quality of care.

That seems to be a big problem here. And Only when the U. S. Centers for Medicare and Medicaid Services threatened the ability for HCA to collect Medicare and Medicaid payments because the standards of care don't meet their standards, that's when HCA finally, only very recently, has stepped up to say, we will come up with a plan.

Am I correct in that whole timeline? 

Andrew Jones: Yeah, it's a really difficult timeline. I think that's a relatively good summary. Look, the attorney general who you just mentioned is involved now, and his lawsuit, by the way, has absolutely nothing to do with these investigations. His investigation was entirely separate from the federal investigation that was happening. 

Matt Peiken: So I don't want to stay on Josh Stein super long in this, but what is his investigation of HCA focusing on?

Andrew Jones: Yeah, so a couple things I'll mention there. Number one, to what you said a moment ago, Josh Stein has been involved from very early on in the process because there's a law that says that essentially when a nonprofit gets sold like this, the AG's office has to get involved and has oversight essentially.

And he can suggest and put some things in. And he did put some sort of barriers and shields in there to make sure that care was as good as humanly possible. From our understanding from the Watchdog's reporting, both my reporting and the reporting mostly of Peter Lewis at the Watchdog, we really think that the AG did pretty much everything that he possibly could to make sure that it was a very robust sort of contract that was entered, that HCA was going to commit to all of these things, to growth and to good healthcare standards over the next 10 years. 

Matt Peiken: But were these standards that Josh Stein wrote into his approval of this, were they vague? Because it seems like that there was no specifics, and even HCA has said, look, there were no specifics in this purchase agreement that we signed. 

Andrew Jones: There were specifics. There were some very narrow specifics. Opening new facilities, for instance, Sweeten Creek, if anybody has driven past Sweeten Creek mental health facility, like that was one of the things that he actually required. So that's very specific. There wasn't anything in there about quality of care, as you essentially mentioned, and quality of care is a very deep and profound subject could have any number of implications, essentially. You have to keep stuff open and you have to build new stuff, but there wasn't anything that essentially said, these need to be the numbers that you produce. And I can't say to you, from my reporting, whether or not he could have pushed for more. 

Matt Peiken: That was my question. Did he? Is he looking back and regretting? I really dropped the ball on this. 

Andrew Jones: I don't know. You would have to ask him. I've tried. You would have to ask him. That would be a fantastic conversation. I think it's an existential moment for all of us, from reporters to elected officials to the attorney general's office is could this have gone better?

I think one of the things that we have to realize is that none of us ever expected, and I say us, but I've only lived here in Asheville for a couple years. But folks really didn't expect it to get this bad, so when you're engineering things at the front end, are you planning for a catastrophe? Or are you planning just for an organized hospital system to be functional for the next 10 years? 

Matt Peiken: You can take that question and look back on, there were people who were critical of the deal before the purchase agreement. So yes. So let's go fast forward. There's the threat of immediate Jeopardy. Explain immediate Jeopardy because that's a term that appears a lot in your articles and it has to do with immediate Jeopardy of not being able to collect Medicare and Medicaid payments.

Talk about the threat of that and how that gets in enacted. 

Andrew Jones: So immediate jeopardy is essentially when there are these things that happen in a hospital that are really bad for patients and they may involve patients getting really hurt by the care that is given or attempted to be given and the systems that design that care, or they may die as a result of that care.

Matt Peiken: And the immediate jeopardy, it's an official status. 

Andrew Jones: Yes, and it looks at those incidents and it says, something made this happen. That something is the immediate jeopardy. And essentially, when a hospital is declared to be an immediate jeopardy, that means that something still exists. And the hospital needs to get rid of whatever that really bad thing is, whether it's a practice, whether it's a policy, whether it's malfunctioning in equipment, whether it's anything, they need to get rid of that thing.

And if they don't get rid of that thing within an allotted amount of time, they will lose their Medicare and Medicaid services. And

Matt Peiken: this brings us back to the very beginning of this conversation where the letter that we were just talking about that doctors and Julie Mayfield and others have said, this plan of compliance that Mission produced in response to this immediate jeopardy status, that it got approved without any guarantee of staffing level. Who approved? Was it that the U. S. Centers for Medicare and Medicaid Services both put Mission in immediate jeopardy and approved the plan of compliance? 

Andrew Jones: That's essentially correct, yeah.

Even though the state recommended the immediate jeopardy, because they're contractors, they were the ones who did the investigation. They made the recommendation to CMS that the hospital be put in immediate jeopardy, which is what we reported early January. And then the CMS sort of reviewed that investigation and said, Yeah, we agree with you.

And they sent a letter to Chad Patrick, the CEO of Mission Hospital on February 1 saying you're in immediate jeopardy, you have 23 days to fix this problem or you lose your funding essentially. And so addressing what you just said about how the plan of, correction was engineered, there's a couple of things there.

Number one, the plan of correction does address the immediate jeopardies. It tries to remove those. Those are supposed to be removed by saturday, February 24th. I think it's saturday. There's also a lot of other deficiencies as well. It's not just these immediate jeopardies. It is a whole raft of issues essentially.

And the hospital has to repair those over the long term as well. But right now we're in a moment Where we're holding our breath through Saturday to see if investigators who are at the hospital, likely as we speak.

We know they were there Tuesday according to the my reporting. They're likely there today and they are prepared to make a decision about whether or not The immediate jeopardies have been removed and funding can continue to come from the federal government. 

Matt Peiken: So and yet this plan of correction, even though they have to address a litany of issues here, it sounds like from what the critics are saying, this plan of correction does not include raising your staffing levels or meeting a certain ratio of staffing to patient. 

Andrew Jones: So this is a great opportunity just to tell you a little bit about what my reporting shows they're actually doing, which is, number one, not pushing to hire more staff, although I think they're bringing in a lot of travelers and I think that there are efforts to hire. We see a lot of job postings online, traveling nurses who have temporary three or six month contracts essentially.

So it's a temporary fix. So we know that Mission Hospital is making these efforts to hire more staff, but that's not actually transpiring in the places where the staff is needed most. So the worrying thing here is that the plan of correction does not say, and there are people who contend that the plan of correction should just be littered with hire more staff in this department, hire more permanent full time staff in this department, hire more full time staff in this department.

Because that's not there, They're worried that these deficiencies will continue. What Mission is doing, according to my reporting, is they're making nurses do more training. They are micromanaging nurses by asking them to sign these attestation forms. They are making them give patients more baths.

The People who are in charge of managing nursing units are being a lot more watchful and a lot more communicative with nurses. There's a lot of stress that's going on there right now, even though from what we hear, less patients are actually coming to the emergency room in January as a result of some of this news has come out.

So we know that Mission is doing these things that are really temporary fixes. And I have to say, there's a registered nurse who I spoke to Jacob Ray, who spoke to me a few weeks back and he talked about all this micromanagement and said, we just need more people. We need HCA Mission to focus on hiring more people because until then, he said, all of this that they're doing is just a bandaid on a gunshot wound.

Matt Peiken: Worse than a bandaid, it sounds like it's overtaxing already heavily worked nurses. Also, one of the things that touches on an aspect of the letter, that one of the complaints was, you're bringing nurses in who are inexperienced, and that, in the past, they're saying pre HCA, you needed a certain level of experience before you could even work in the emergency room, for instance. Now they're taking according So, to the allegation in this letter is that a lot of people fresh out of nursing school are now going into the emergency room, which is also creating some problems.

Andrew Jones: Yeah, that's been actually a concern of nurses for years. And they've flagged that internally. They keep telling, their chief nursing officer we don't need just more people. We need also experienced people, but this is a good opportunity to just talk briefly about traveling nurses, who may be from anywhere in the United States, they come here and they're not part of the community. And even though they may have years of travel experience behind them, or just months of traveler experience behind them, not being a part of this community is something that people are saying nurses, doctors elected officials is really a problem.

Because remember, before HCA, this was a very sort of neighborhood, community oriented health care system. And now what we're seeing is just a lot of contracting out, bringing people in who don't know the system, who don't know the needs, who are unfamiliar with Mission and Asheville and the surrounding areas.

Matt Peiken: Why does that make a difference in healthcare and when you're nursing quality nursing in Asheville should be the same as quality nursing in Santa Barbara, California. 

Andrew Jones: Precisely. Yeah. And, the way I think about it and the way that it's been described to me is that, imagine working on a team of 20 people at your business, but 15 of those people keep getting replaced and replaced and replaced. So turnover, turnover, turnover. Turnover, as I think anybody who works at a company can attest to is really stressful and very difficult to manage and creates just deficits in communication. 

Matt Peiken: But also trust, the trust in knowing each other.

Andrew Jones: Imagine trying to work with a new person who you've never met with on a weekly or a monthly basis and then amplify that 12 times to say, I'm working with this person to save lives on a daily basis. Now, that's how our health care system is set up across the United States right now, but we know that it is especially intense at Mission Hospital, that they're just working with travelers.

Matt Peiken: You're touching on something I wanted to just ask you. Why is HCA having such a problem hiring nurses? You would think that, the job should pay well. People are graduating nursing school to go in this profession. Have you learned any reason or Is Mission having a problem with staffing in a way that hospitals everywhere aren't?

Is it different here? What's going on here that's different than other hospitals? 

Andrew Jones: Two things about that. I did some reporting in mid 2023 about the nursing deficit in all of Buncombe County and there's a nursing deficit, not just that Mission. But also at a lot of nursing homes as well.

That's tracks with a statewide trend. There's some really great data out of the Sheps center that talks about just deficiencies there. And then across the country, we're dealing with nursing shortages, especially after Covid 19. It has become a very difficult industry to work in. But here at Mission, and I've heard this from people who run nursing colleges and saying that actually the media on Mission is something that drives applicants away.

They don't want to work at a place that has a reputation for being as problematic as this place. Now, that is not something that I can prove with data. I'm saying it anecdotally essentially, but I also believe nurses when they say it's difficult to get people in because they're worried that this might not be the career that they were looking forward to. So Mission now having this immediate jeopardy has to deal with a further dent in their reputation, which I think it's reasonable to say will make it even harder to hire people. 

Matt Peiken: So these auditors who are in now to check on conditions at the hospital, who are looking to see if this plan of correction is being adhered to, what happens at either fork in the road? Let's say they just say yes you have abided by this plan of correction. Does this let HCA and Mission off the hook? That the investigators go away? There's no more checking on them? What happens if they determine that this plan of correction is being followed? 

Andrew Jones: If they determine that the plan of correction is being followed, then we enter a healing, a very serious healing phase. What we are going to see likely is more oversight than we did before because there's so many things to fix. But if we get the news in the coming weeks or days that indeed the immediate jeopardies have been removed and there's no longer a threat of funding loss, then we'll go into a Long term employment of the plan of correction and it will last for a while. It's hard to say how long. 

Matt Peiken: That's what I was going to ask you. Is there a probationary period or anything like that? That we are going to continue to monitor HCA for 18 months. I was just curious if there was 

Andrew Jones: anything like that. There's some permanent fixes, I can say. There are some ways that Mission is currently are already has restructured its policies, adding new policies, changed the way it does certain systems.

Some of those are, in theory, really great. Some of those in practice are really pushing nurses even more beyond their limits than they are before. So some of those changes are permanent. And actually, I think when you look at it in an ideal situation, you say, Yeah, these should all be permanent fixes, nothing should be temporary.

Matt Peiken: Regardless of the plan of compliance.

Andrew Jones: Yeah, exactly, there's, there are things that we have to do to dig out of this hole necessarily, but those things should go on long term. And I come back to that band aid on a gunshot wound phrase from Jacob and what nurses have told me is that they are incredibly afraid that any good policies that are being implemented right now might go away when surveyors are no longer watching.

Matt Peiken: That's what I was just wondering. You hear about like restaurants that, oh, we learn when the inspectors are coming in, we clean up and then when they go away, okay, we're going to go back to the natural inertia of the way we do business.

Andrew Jones: But you know, Matt, just think of American capitalism, think of our economy. Think of 2008. Think about how regulation and oversight works. I think we especially in the after the turn of the century have been incredibly just cognizant that when people are looking big companies behave. And when they're not looking, they don't. 

Matt Peiken: So now what happens if the investigators determine that the plan of correction has not been followed or you have fallen short, Mission HCA, of this plan of correction, what happens then? 

Andrew Jones: So there's, you can actually look up this law about immediate jeopardies and the removal of immediate jeopardies, and there's a couple little bullet points under it, and it says, If the immediate jeopardies aren't removed, there are two things that happen.

Category one is you lose funding and the other category is like other. So I think there is actually a pretty wide series of options for what penalties or what fixes could look like if the immediate jeopardies have not been removed. But that is a lot more of a veiled process.

Matt Peiken: Yeah, that's really interesting. Is it also subjective? Like, A judge has discretion. Obviously taking away the ability to collect Medicare and Medicaid funding would be the death penalty, right? And then anything short the other is maybe more livable or manageable. 

Andrew Jones: I'll be very honest with you is that I've spoken to patients and doctors and to nurses who have said Maybe it should just happen, Maybe it should just happen so that we realize how grave and how dire this situation actually is.

The other side of that coin is that if it does, that throws an incredibly chaotic wrench into the system. Nobody wants this to happen. 

Matt Peiken: If that does happen, does the hospital close? 

Andrew Jones: I don't know. It's hard to say because When Medicare and Medicaid funding is suspended, then the hospital has to figure out another way to do it.

Essentially, it may turn to funding itself for the 10 days or the however long, that the funding is actually suspended. 

Matt Peiken: Did you have a sense of what percentage of revenue for HCA is derived from Medicare and Medicaid payments. 

Andrew Jones: 75%. That's the lifeblood. Yeah, it is absolutely the lifeblood.

It would be, again I can't emphasize enough, it would be catastrophic for this to happen. And this isn't just any hospital. It is a tertiary care center that is the centrifuge of five regional hospitals. Even in a decision on a lawsuit in federal court that came out yesterday, there was a judge who was agreeing that, yeah, People are being filtered from other HCA hospitals and indeed from other non HCA hospitals in the region to this hospital.

This is the hub and it's not that these other hospitals aren't important. They're incredibly powerful spokes that make the wheel of hospital care in Western North Carolina. But people are being sent here because there's care here that can't be provided anywhere else in Western North Carolina unless you're going to Charlotte, which is a couple of hours away.

Matt Peiken: Yeah, so maybe for that reason alone, The so called death penalty wouldn't be imposed just because of the harm it would create in this region. 

Andrew Jones: You got it. Yeah, you got it. It's Too big to fail. It's too big to fail even if it is failed. And they say that about some of the banks, exactly.

So you get this pattern, you know, these companies get too big for regulation even to hit them in a way where it hurts. Again, this is all speculation, but I think, what we're talking about right now definitely gets to the seriousness of this. 

Matt Peiken: How many hospitals or medical centers every year have been given this so called death penalty? 

Andrew Jones: So I can't tell you that precisely, but I can give you one of my favorite factoids about this situation. When I broke the news that the state was recommending to CMS that it imposed immediate jeopardy, I found a study and that study said that a media jeopardy is rare.

This study is from 2021 And it's from the National Library of Medicine. That study reviewed 30, 808 hospital deficiencies between 2007 and 2017. Only 2. 4 percent or 730 of those hospitals resulted in immediate jeopardy. This is incredibly rare for this to happen. 

Matt Peiken: Well, 2. 4 that's a very fractional amount, but it's not nothing.

Andrew Jones: It is not nothing at all. Hospitals Get into issues all the time, hospitals face deficiencies inspections happen all the time. It is definitely a thing. What I would point out is that Mission Hospital, according to national ratings, I'm not just talking about health grades and leapfrogs, which are very problematic rating companies. National ratings said that this health care system in Western North Carolina was one of the best in the nation.

It was on top 15 lists when it was a nonprofit, when it was a nonprofit. And so I think it's shocking for this community. To turn around five years later and wake up and see that their hospital is facing the most Serious sanction that any hospital could face.

Matt Peiken: I'll leave you with this question: is this just complete folly in thinking that a scenario could occur that the death penalty be imposed, is HCA say this doesn't fit our profit model.

We're going to sell Mission Hospital. We're gonna get outta this hospital 'cause it's just proving too problematic for us. And it becomes a nonprofit again. Is that just too ridiculous to even consider? 

Andrew Jones: I wouldn't say that it's ridiculous to consider because there are people speaking very publicly about it.

It is a conversation that is no longer whispers in back rooms. It's something that is being had on stages in front of the public. The Watchdog hosted a forum with a number of experts. Talking about these issues a number of weeks ago, you taped that and generously published it as well, and that suggestion came up a number of times, and it received applause.

Matt Peiken: It received applause, but nobody on the panel said, yes, that's a possibility. 

Andrew Jones: Precisely, because at the end of the day, nobody gets to make that decision except HCA.