ASHEVILLE - Citing an influx of complaints his office has received about Mission Hospital, state Attorney General Josh Stein on Feb. 25 asked for some accountability from hospital owner HCA Healthcare.

In a letter to HCA's state leader, Stein listed four areas of concern: quality of care, charity care implementation, billing inconsistencies and the absence of a sexual assault nurse examiner at Mission's Angel Medical Center in Franklin.

"Some of the stories in these complaints are harrowing to read, and we are taking all of them seriously," Stein wrote in the letter addressed to Greg Lowe, president of HCA's North Carolina Division.

In an email to The Citizen Times, Mission Health spokeswoman Nancy Lindell said, "We are aware of the comments in Attorney General Josh Stein's letter; we have been communicating with his office and we welcome the opportunity to continue the discussion with him about our commitments to our community."

In January 2019, Stein announced he wouldn't legally challenge HCA's purchase of Mission after all sides agreed to 15 commitments for HCA to uphold.

Since the $1.5 billion sale closed, numerous patients and at least one nurse have voiced concerns over the state of Mission Health under HCA management. Many of those complaints came at a series of seven meetings across WNC with the independent monitor hired to ensure HCA is complying with its purchase agreement.

"Widespread quality of care issues at Mission facilities would raise real questions about whether HCA is providing the services that it guaranteed," Stein told Lowe, in reference to the HCA-Mission purchasing agreement. Throughout the letter, Stein cited the agreement and conveyed that his office would investigate whether HCA is upholding each of the 15 commitments.

Stein said his office has received 30 written complaints since the start of 2020. Copies of those grievances will be provided to HCA and also will be forwarded to the N.C. Department of Health and Human Services, which monitors hospital regulations.

The Citizen Times had requested any complaints filed with Stein's office prior to Stein's letter; the office's public information officer acknowledged the request upon receipt.

Related:

Concerns about quality, services

On quality of care, Stein noted complaints to his office aligned with ratings that Mission Hospital had received in a measure of patient satisfaction.

In Leapfrog Hospital Safety Grades, Mission received a "C" in the most recent ratings, last fall. That is a decline from the "B" it got in spring 2019 and fall 2018, and the "A" received four other times between spring 2016 and spring 2018.

Stein gave HCA the tightest deadline on answering concerns raised about the lack of a sexual assault nurse examiner at Angel Medical Center in Franklin. HCA is to look into this by March 4.

Citing the purchase agreement's language that says HCA "shall not discontinue" Angel's emergency services, he noted "SANE nurses’ support to sexual assault survivors, in an emergency or acute medicine setting, is time-sensitive and of critical importance."

On billing, Stein asked for the disclosure notice that patients are receiving about outpatient fees that may have been charged for services rendered outside the hospital.

HCA's charity care questioned

Stein cited "concerns with the way in which HCA's charity care and uninsured patient policies appear to have been implemented."

He cited four specific concerns:

HCA wrongly understands charity care to cover only urgent needs.

It is not easy for doctors or patients to learn how the charity care policy is applied.

The policy is not consistent with the Asset Purchase Agreement.

Mission's own website doesn't describe the policy on financial need in the same way as that agreement.

Stein also faults the hospital's process of having charity care decisions run through the chief medical officer, Dr. William Hathaway.

"He is clearly approaching these duties in a principled and thoughtful way, but his busy schedule makes it impossible for physicians to easily contact him," the attorney general wrote.

EDITORIAL:The alarm has been sounded on HCA's Mission management

911 IN ER?:Keep your phone with you in the ER in case you need to call 911

FEEDBACK AND ISSUES:7 ways to make your voice heard about Mission Health

To determine whether HCA is in compliance with its charity care guarantees, Stein asked Lowe for documentation on nine points, ranging from utilization rates, the dollar amount of financial assistance offered and a list of all staff who are making coverage decisions for HCA's financial assistance policies.

Stein gave Lowe a March 11 deadline to provide all of that information — about two weeks.

Brian Gordon is the education and social issues reporter for The Asheville Citizen Times. He can be reached at bgordon@citizentimes.com, at 828-232-5851, or on Twitter at @briansamuel92.