PART 1: Sub-Mission | State Sen. Julie Mayfield, Retired Dr. Bruce Kelly, Chaplain Missy Harris of Reclaim Healthcare WNC

So much has been written and said in the five years since the corporation HCA Healthcare purchased Asheville’s nonprofit Mission Hospital. Doctors, nurses and other staff have fled amid what many see as the company’s push for profits over people. North Carolina’s attorney general has filed lawsuits. Nobody involved in the original deal has spoken candidly about how this sale even made it across the finish line.

Today is the first in a two-part conversation with leaders of a new coalition called Reclaim Healthcare WNC. They are State Senator Julie Mayfield, retired physician Bruce Kelly and Missy Harris, who recently left Mission after five years there as a chaplain.

We delve into the significant changes at Mission after its acquisition by HCA, the changes this coalition wants to see and why, after all that has been said and done to chasten HCA to this point, the people behind Reclaim Healthcare WNC believe they can hold HCA to account and inspire substantive change.

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Transcript

Matt Peiken: In some sense. You could say almost in a stereotypical way that this is a villain and hero movie in a way, and it almost sounds like it's almost too simplistic that simply selling [00:03:00] to a for profit entity would result in the cascade of allegations and documented loss of quality that has happened. And is it as simple and any of you, could answer this but is it as simple as going from non profit to for profit That precipitated that caused all of this to happen?

Julie Mayfield: I think the answer to that is no. There are plenty of for profit companies that do well by doing good. This happens to not be one of them. This company, HCA, is single minded and rapacious in its pursuit of profit to benefit its shareholders.

It doesn't have to be that way. But that is their business model. And that is the way that they have managed and run this hospital. And it absolutely does not have to be this way. This is What we like to [00:04:00] say is a crisis of choice. This company, HCA, has plenty of resources. Their profits are at an all time high.

They are one of the most profitable hospital companies in the entire country. They are choosing to underinvest in the healthcare community and our hospitals here in Western North Carolina. That is an affirmative choice that they make. 

Matt Peiken: You say it's a choice of theirs. Can you give me an example or two of for profit corporations that own hospitals and healthcare systems that are, in your estimation, doing it right or at least doing it fairly? 

Julie Mayfield: So I should start by saying there are not very many for profit hospitals in North Carolina. HCA is I think the, probably the biggest. The other good partnership that's out there is between Duke University and LifePoint. So LifePoint is a for profit company, Duke University, obviously a nonprofit.

Matt Peiken: Would you call that a public private [00:05:00] partnership?

Julie Mayfield: A private nonprofit partnership for sure. It's not public because Duke University and the medical system is not public, but it is a partnership and my understanding of that partnership is that LifePoint is the owner of the hospitals and the facilities and Duke provides the medical care, like Pardee hospital. Pardee is in Hendersonville, is owned by the county, but the UNC healthcare system provides the healthcare in the hospital. And I just can't underscore this enough. I do think having that nonprofit partner Is key because nonprofits are mission driven.

That is not to say that nonprofits do everything right. And that's not to say that nonprofits don't also desire to make a lot of money and reinvest that money. But those nonprofits are, in fact, required to invest that money in nonprofit purposes. And [00:06:00] HCA has no such limitations. They are not mission driven to provide quality health care or to make people healthy. That's not their mission. 

Matt Peiken: Yeah, Julie when this sale happened, you were in city council. Did this kind of fly under the radar of everybody?

Julie Mayfield: No, it did not fly under the radar. We were very aware of it. The community was very aware of it. We had several joint meetings between the county commission and the city council with Mission Hospital personnel, Ron Paulus, talking to us about what this meant because we had a lot of questions. The problem was, there were so many problems, but part of the problem was that the Mission Hospital representatives were, they were either telling us what HCA had represented to them, which we now know was a lie, or they were affirmatively lying to us. I don't want to attribute that to them. I don't want to think that they had those kind of [00:07:00] motives. So I'm not going to do that. The key thing, Despite our repeated requests to speak directly with HCA officials, They never came. They never spoke to us directly. 

Matt Peiken: You've said there were direct lies, and if you don't want to attribute them, can you say what those lies were? 

Julie Mayfield: So the message to this community from Ron Paulus and other senior executives at the hospital was, nothing will change. And when we asked the question, if Mission is running on thin ice and a thin profit, and is eventually not going to be profitable, how is a for profit company going to make it profitable? And the answer was we're going to consolidate back office functions like accounting and things like that. So we'll save money there. And the purchasing power of HCA, which is tremendous.

So they can purchase an MRI machine for a lot less money. And those were the two ways they were going to save money. I remember specifically asking the question about the contracts that Mission had [00:08:00] with physician groups like the ER physicians and the hospitalists and the oncologists and things like that.

And the answer directly from Ron Paulus's mouth was nothing will change about those contracts. Those contracts will be renewed and nothing will change. That of course was not the case. That is not what happened. And again, I don't want to say that Ron Paulus was lying. That might have been what he thought would happen, but that is absolutely not what happened.

And I'm going to say the refusal of HCA to renew those contracts on fair terms to the physicians is a huge piece of what has Destroyed our health care community.

Matt Peiken: And didn't Ron Paulus end up going to work for HCA after this transaction?

Julie Mayfield: He did for I think a short period of time.

Matt Peiken: Okay, 

Julie Mayfield: and that doesn't even bother me.

It 

Matt Peiken: doesn't? I would think on the surface, on mere appearances, That would appear a huge conflict of interest.

Julie Mayfield: Yes, [00:09:00] and it's not crazy to me to think that in a transaction of this size that the leader of the system would go to work for the purchaser to help smooth and ease that transition. That's not inconceivable to me. That actually, in many ways, makes sense to me. I don't know if that's what happened. 

Matt Peiken: It certainly didn't smooth and ease the transition. It did not. Yeah. 

Julie Mayfield: It did not. 

Matt Peiken: So Missy, I want to talk to you a little bit. So you were a chaplain at Mission for five years. When was this?

Missy Harris: I was there from 2018 to 2023. 

Matt Peiken: Okay. So you were there during the thick of this. 

Missy Harris: Yes. 

Matt Peiken: Tell me what were you hearing internally? You work across departments as a chaplain there, I imagine. So Give me a sense of the conversations that were happening internally among staff when whispers of this transaction were going to go forward.

Missy Harris: People were very uncertain and nervous and among chaplains, the [00:10:00] conversation because we're connected with chaplains in other settings through various networks, We reached out to chaplains at other HCA facilities and were able to just get a sense of, okay, what's coming down the line for us, not just for us as chaplains, but what should we be aware of that is going to impact staff in our system with this change.

And that was a helpful thing because we were able to anticipate what was coming down the line for us. And we knew that our department was going to face some really serious cuts and it eventually did. And among staff, there was nervousness just not knowing what this was going to entail in terms of staffing ratios and the ways in which the hospital functioned in a collegial manner. Over time that began to break down and persistent understaffing has been across the board from about, I don't know, six months after [00:11:00] HCA arrived we began to feel some of in terms of what Julie was naming that, it was stated no, those things aren't going to change.

We're not going to, we're going to not going to mess with that equilibrium that is working. But what we begin to see about six months in was that slow chipping away. And then it became more and more dramatic over time. 

Matt Peiken: You mentioned staffing reductions. Now, we can't even begin to go into the litany of complaints that have happened around HCA. Talk about when these things were happening at Mission about being able to talk to your superiors and people in management in upper management.

Did that pipeline of communication functionally change with the change over to HCA? Were you able to talk with your managers before and not now? Or what changed around that? 

Missy Harris: Absolutely. As the chaplaincy department, we reported to the office of patient quality care and satisfaction. And our supervisor was the person who received all of the complaints, which made a [00:12:00] lot of sense because we would find ourselves in spaces in the hospital where things were feeling a little wrinkled, or patients were having trouble navigating things, and it made total sense that we were under that umbrella.

By the time I left, we were under the same department that oversees parking and security and volunteer services. 

Matt Peiken: Wow. 

Missy Harris: So take that leap. 

Matt Peiken: How did that match up with what your work was?

Missy Harris: Our work continued to be the same, but our access to and ability to connect with our supervisors in the same kind of way really shifted.

And in the five years that I was there, our management structure changed at least four times that I can recall in terms of just shuffling in and out of different roles, trying out, okay, we're going to now have the person who oversees volunteer services, oversee the chaplaincy department, which to some degree made sense.

But when it [00:13:00] expanded more than that and we fell under the same category as parking services, like it just got further and further away from the core of the work that we do in terms of caring for patients, families, and staff in a pastoral way to we just were not able to cover everything. And our numbers were slashed in such a way that there were, in particularly at the height of the pandemic, HCA thought it was sufficient to have one chaplain on duty at any given time in the hospital covering both The Memorial Mission side, as well as the St. Joseph side including Copestone, which was an impossible task. 

Matt Peiken: Now there also were lots of stories around people leaving of their own accord because they couldn't stomach what was happening there. From your vantage point, what hasn't been reported so much or what has been under talked about that you from the inside and you or your colleagues were talking about that have been fundamental erosions of either care, [00:14:00] functionality. What do you think the media in general has not been as reporting about that you think should get more attention? 

Missy Harris: One of the most disturbing shifts for me was around end of life care and the processes that quickly eroded over time once HCA entered the picture.

Chaplains used to be deeply involved in the end of life process. We would get calls to every death that happened in the hospital system. And there was a particular portion of the paperwork that we assisted nurses filling out because we were naturally already having those kinds of conversations with families.

And so when a person passed away in the hospital we would already be with families and they would be asking what do we do next? They're in the midst of deep grief and sometimes disbelief that they're even in a situation that was completely unexpected in terms of some sort of tragic event that happened to their family member.

And so we were already in those conversations and [00:15:00] could begin to say, okay The first step is, do you know what funeral home you want to use? And if they, sometimes it was people who were just passing through and had this traumatic event and they had no idea what funeral homes to even use.

And so we would accompany people through that process and help them know, okay, what's the next step we take? HCA assumed ownership, eventually chaplains were taken out of that process completely. And I don't know that there's a direct link between this, but it coincided right around the time that the nurses were unionizing.

And I think it was an action and retaliation for that. Chaplains were told, no longer do you touch the death paperwork. You don't have that conversation. You don't sign anything. That's on the nurses. And so those conversations then were added to the clinical work that nurses were already attending to after a death.

There's a list of things Several things that they have to go through in terms of phone calls that they need to make, reports that they have to complete. So in addition to those things, clinically, they were now asked to have these deeper conversations around what funeral home do you want [00:16:00] to use?

And when you're, when you're in a situation where it's a travel nurse, They can't even tell you the funeral homes that are available here locally. And I, one more thing I do want to say about that is that a dramatic shift that has happened that Has not gotten a lot of coverage yet Has been around the morgue and the office of ascedent affairs, which is what we refer to the morgue as internally at the hospital. The morgue staff was reduced dramatically over the course of the first three and a half years, to the extent that now what happens in the hospital, when a person dies, security guards are now tasked with coming to the room.

Once the nurse has prepared the body, put the body in a body bag, now a security guard comes to the room and transports that person's body to the morgue. Prior to this, we had a trained morgue staff who Kind of knew the nuances of engaging with a [00:17:00] family. Security guards are doing the best that they can around this, let me say that clearly. And it's not in the general Purview of the work that security guards are tasked with, so they're walking into situations with families who are in deep grief, and it's everything from a 96 year old who has died at the end of a good full life to Someone who loses an infant. And the optics of a security guard coming to transport your family member's deceased body to the morgue is just, it's unconscionable.

Matt Peiken: Yeah. Between removing chaplains from the conversation to removing more trained technicians, if that's their title from the end of life aspect of this, it all speaks to a dehumanizing and very clinical, not medically clinical, but just a very cut and dried approach to, to, I, I wonder what, cause some of this doesn't speak to dollars and cents.

What would be the rationale for taking [00:18:00] chaplains out of the equation of these conversations? 

Missy Harris: I think one piece of it is that a chaplaincy visit is not a billable expense. So it is not a priority to, in my opinion, that, that is the rationale, not knowing internally what those conversations are among executives.

And just another practical example of what that looks like, I worked mostly overnight as a chaplain. And often When there was a tragic car accident with someone who was passing through, not from this area, it was my task to figure out who family was, make that contact, and help that communication happen as their family member is being cared for here until they can get here. If that family member did not survive whatever accident had occurred, and A family member is coming from 6, 8, 12 hours away, often there was space that could be created by nurses to have the body in a room so that the family could get there, view the body, and [00:19:00] then the body would go to the morgue.

What happened after HCA made some of these changes was that family members would arrive and The body would have already been taken to the morgue and I would have absolutely no ability to take that family member to see their family member's body. And the only option that they have is once they make a decision about a funeral home, to see the body there.

And prior to them Just dismantling the morgue staff. I would be able to call the morgue and say hey this family just arrived here, The body was taken four hours ago, Can I bring them down? And there wasn't a great space there. It's a tiny space but the morgue staff always went above and beyond to accommodate that and do what they could to enable family members to Come in and View their family member's body and taking that away in those circumstances was just excruciating.

I can't tell you the number of family members that I sat with in lobbies and [00:20:00] they were just weeping because there was zero that I could do to help them. 

Matt Peiken: Wow. In that process. 

Thanks for elucidating all that. Now we're here today because you are all part of the founding of Reclaim Healthcare WNC. And I want to talk about just the very genesis of this.

It seems like this formed or started taking shape in October, right? Last October was the beginnings of this. And Josh Stein has been on this. There have been outcries from doctors, nurses, other staff, pressure campaigns, media blitzes the Asheville Watchdog in particular has been, Andrew Jones is a full time reporter on this.

And yet, HCA seems impervious. There's been nothing of an official response at all substantively to any of the accusations, any of the allegations, any of the lawsuits, nothing that they've come out publicly with any [00:21:00] substance. I have to ask all of you, what do you think you can accomplish with Reclaim Healthcare that so far has not been accomplished?

Julie Mayfield: So there has been certainly a lot of coverage and conversation about what's happened at the hospital over the last five years, but there has not been an active campaign in any way. My engagement with all of this started actually back right before covid when the independent monitor first came to town for their first series of public meetings. And at that point, I gathered together elected officials and said it's time. As leaders in this community, we need to make a strong statement about how dissatisfied we are and frustrated we are about what's happening at the hospital based on everything that we're hearing from our constituents.

And so that happened. I think that was in January or February of 2020. [00:22:00] And that meeting that happened here and that letter got a lot of publicity. And the call at that point from the elected officials was let's sit down. We want to sit down with you. We want to try to make it better. I want to try to make it better.

And we had one meeting with the hospital leadership and then COVID hit. And so obviously everything turned for over two years really. And then I tried to start getting back to the conversations with HCA about how do we fix things. I'll just say that was not a constructive effort and I was basically told you might just want to move on.

Matt Peiken: Let me ask you, what do you think changed aside from just the two year span of COVID from at least being at the table, it seemed like you were having conversations before COVID, no matter how rudimentary or beginnings they were, to them saying, move on. What changed? 

Julie Mayfield: I think they were tired of the conversation. In their mind, they had moved on. But as I explained to [00:23:00] them, the people in this community have not moved on because things have not gotten any better. Coming out of COVID, they're not any better and the same concerns that we had back after your first year are still present today and we have to figure out how to address them.

Matt Peiken: Which is, on some surface, you have to wonder, how do they keep passing these quality of care tests? You keep hearing that there are these national organizations that come through and rate them and they get passing grades, extraordinary grades to some degree. What do you say in response to that, doctor?

Dr. Bruce Kelly: There are real questions about the value of those monitoring, Leapfrog health grades. There are major questions about whether those are meaningful or not. They look at statistics, they look at data and that data and those statistics are provided by HCA and they know how to do this.

They know how to make themselves look good with what is being measured. But what is not being measured is what we hear about day after [00:24:00] day. There's a evaluation referred to as H caps that monitors patient satisfaction this is a national monitoring platform.

And in the five years prior to the sale, patient satisfaction admission was consistently four or five out of five. And in the five years since HCA has taken over, that has declined year by year. And in 2023, patient satisfaction across three domains were one and two out of five. So the experience of the patients at the hospital, in addition to what we've heard about safety and quality, are just real concerns.

Matt Peiken: How do you then square what you're seeing in terms of the declines from patients, the mean score decline there, and then Leapfrog giving these high scores. You mentioned that HCA is providing these numbers themselves. Julie referenced an independent monitor, but is there no [00:25:00] independent scoring of different metrics that would go to these rating agencies?

And in a way, what you're saying is HCA and any other hospital chain self polices, self grades, right? Am I being simplistic about that? 

Dr. Bruce Kelly: No, you're being accurate. That is essentially what happens. Recently, we saw that recent medicare ratings gave them a four star, Which we were all just stunned to see. I mean, you've seen the news about the nine cases of immediate jeopardy That were found by DHHS right this past december, including four deaths in the emergency department. How you jive a four star rating with a hospital has had an unprecedented number of immediate jeopardies and deaths is just beyond us.

Now

Matt Peiken: Explain the immediate jeopardy element from what I understand, correct me if i'm wrong in this, when a hospital Faces immediate jeopardy, they either have to substantively correct things that have been found in error Or they can lose their [00:26:00] ability to accept Medicare and Medicaid.

Am I correct in that? That's correct. And how does a hospital so quickly change if the, if they're in immediate jeopardy, these are consequential statuses that I can't imagine things can be corrected so quickly, yet it's seemingly HCA made quick corrections. 

Dr. Bruce Kelly: We took a look at Their plan of correction, all 384 pages of their plan of correction.

And to our judgment and assessment about that, it did not address the central issue, which is the staffing issue. Prior to HCA's purchase, the average number of staff at mission Per patient was 6. 1 full time equivalence. It's now 3. 7. 

Matt Peiken: That's crazy So it's almost like 40 or more easily. 

Dr. Bruce Kelly: Yeah, the statewide average is 5. 1 and essentially All of the problems come down to a reduction of staff and [00:27:00] loss of resources and services that have been cut in the name of profit. As Julie said, they've been rapacious and that this is a choice they are making that benefits their shareholders and their executives at the expense of those of us in Western North Carolina.

Matt Peiken: Julie, you wanted to add something. 

Julie Mayfield: Yeah, so HCA is very adept at, I would say, manipulating the data or putting in place policies and practices that will ensure their data is as good as it can possibly be. And here's an example.

HCA instructed their ICU physicians at one point to patients who were going to die, change the way that they get dealt with. Because mortality in the hospital is one of the factors that these rating systems look at. And so the ICU physicians were instructed when a patient was about to die, to discharge them from the hospital, not physically, but on paper, discharge them from the [00:28:00] hospital and then readmit them under another category of palliative care or something like that. Hospice, you expect patients in hospice to die, right? So those people are treated differently.

And we know this because We talk to physicians in the community, and we know that there were physicians who resisted that change because there is only one reason to do that, and that is to manipulate the data. We don't know all of the ways in which they do that. But that's just one example. And if they're doing it there, they're doing it in other places. 

Matt Peiken: Yeah, Missy, you wanted to add to this element? 

Missy Harris: Yeah, just in relation to something Bruce was naming earlier around the understaffing as a chaplain, most every shift that I worked, particularly toward the end of my time at Mission, I would cross paths, not only with physicians, But with nurses, in [00:29:00] tears, because they could not offer the level of care that they knew that they could offer and wanted to offer patients, but they were in an ICU setting being asked to care for four to five patients when they really should have had two to three at the most.

And they were standing there weighing out this impossible situation of I do my best to offer whatever care I can to these, X number of patients that I'm caring for. And when I do that, I know that I am putting my license on the line because I don't have the capacity to offer ICU level care to this number of patients at the same time. And a similar thing was happening in the emergency department. Emergency room nurses were being asked to care for ICU level patients because the system was jammed up in such a way that they weren't able to transfer patients from the emergency department to ICUs quickly enough. So it just [00:30:00] became this problem that layer upon layer of impossible situations for staff who are standing in front of patients and families and have to do what they can in the moment, but aren't necessarily given the tools and the resources in terms of other staff to support that work at the level of the quality of care that we were accustomed to prior to HCA's arrival when staffing was not an issue then. And so again, Mission wasn't perfect before HCA's arrival, but the priority was With patients and offering the best care that we could offer. When this shift happened, It was clear that the priority was to get more money into the shareholders pockets And that shift was just palpable in the whole system.

Matt Peiken: Let me ask you and I don't know if julie you're Maybe the best to answer this. You're an attorney. Now Josh Stein has I've tried various angles to get to the heart of this, but I'm [00:31:00] wondering, he signed off on the initial deal, and it seems to my distant reading of this that maybe he didn't do what he could have done, I want you to respond to my supposition, that he didn't do what he could have done to write into the initial purchase agreement some iron clad Quality of care metrics that would be more enforceable today had he done so. Am I off base in this? 

Julie Mayfield: So let me address this because a lot of people are Frustrated with Attorney General Stein for having approved this deal and I will say a couple things about that. Number one, North Carolina law did not give him and does not give the Attorney General the authority to Prevent or deny these deals.

I have, along with some Republican colleagues, introduced legislation that would do that directly in response to what we have experienced here in HCA. That legislation would give the Attorney General and DHHS much broader authority to look at these deals, look at the impact on the cost, [00:32:00] the quality, the availability, and the accessibility of care.

Those are the four goals. We don't have that. Josh Stein was incredibly limited in the scope of what he did. And frankly, he pushed beyond the bounds of his authority to get the agreements and the commitments in the asset purchase agreement that he did. And that has to do, as everybody knows, with providing certain kinds of care at certain hospitals for certain periods of time.

Now, the issue of quality care metrics was absolutely on the table. HCA pushed back and said, we don't want those and the Mission Hospital representatives acquiesced. Why? I don't know. None of us were 

Matt Peiken: in that room. 

And you're saying Mission Hospital acquiesce, are you speaking specifically of the board? 

Julie Mayfield: I don't know. Again, we were not in the room. This was being negotiated to some degree at a staff level, at an attorney level. My guess is the board was not integrally involved in drafting the [00:33:00] agreement. That's not the role of a board. Their role was to ultimately approve the purchase or the sale, I guess I should say. 

Matt Peiken: You're saying Josh Stein, his hands were tied to some degree. 

Julie Mayfield: So he, ultimately, it was the Mission board that got to make this decision. And a lot of people don't know this, but when Josh Stein started digging into this deal, he found All sorts of irregularities. He found that Ron Paulus had actually begun conversations with ACA prior to the board even deciding that they were going to sell the hospital.

And I think the record is very clear that Ron Paulus And a consultant named, I think his name is Paul Green, steered this entire deal to HCA. What you should have done, what any, what anybody should have done, was say, Alright, a board, we're going to sell the hospital, we're going to put out a request for proposal and get proposals from multiple companies, about buying our hospital, and then we're going to choose the one that we think is going to do best. That is not how this deal [00:34:00] went. 

Matt Peiken: There was one other company that was even at the table, and apparently they didn't have the same seat that HCA had. 

Julie Mayfield: They did not have the same seat. Josh Stein forced the board to receive a presentation from, that was Novant, forced the board to receive a presentation from Novant, but it was at the last minute.

As I say, the board was between third base and home plate, and they were not about to undo all of the work that they had done. And in fact, my understanding is they voted to reaffirm the sale to HCA right after Novant walked out of the room, essentially. So once the board had done that ,Josh Stein's hands were tied.

And if the mission board was saying, no, we don't want these things. We're not going to insist on these things in the agreement, he really had little leverage to push them.