Noncompliance issues plague Mission Health

HCA Healthcare could be in noncompliance with the asset purchase agreement for its 2019 acquisition of Mission Health Systems in Western North Carolina for the third year in a row. It’s also been three years since then-Attorney General, now-Gov. Josh Stein filed suit against HCA for violating the purchase agreement and this week, the NC Business Court issued a key decision in that lawsuit. 

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The purchase agreement is a set of legal documents between Mission and HCA that define the conditions of the sale of Mission to for-profit HCA, which purchased the hospital system in 2019. The agreement includes certain provisions that the attorney general placed on HCA to retain certain services that Mission provided before the sale. 

New potential noncompliance

Affiliated Monitors, the independent monitor that Dogwood Health Trust has appointed to oversee HCA’s compliance with the Mission acquisition deal, sent its annual report to the attorney general on July 24. The report found two issues of potential noncompliance in the oncology and trauma services departments. There’s also a new issue this year, which is the loss of industrial rehabilitation services at CarePartners, the post-acute care arm of Mission. 

Gerry Coyne, an attorney with the Independent Monitor, said the service has not seen any patients since April 1, 2025. Industrial rehabilitation is a type of occupational healthcare where patients can receive long-term rehab in order to return to work. This finding, he said, is limited to Mission Hospital in Asheville and not to any of the other facilities in Western North Carolina that the health system operates. 

Another potential noncompliance is Mission’s failure to remain in good standing with the Centers for Medicare and Medicaid Services. In the past five years, Mission has received four “Immediate Jeopardy” citations from federal regulators. This warning is the most serious from CMS and means that a medical service provider has caused, or is likely to cause, harm or impairment to recipients of their care. 

“We are in regular communications with HCA, but we have not heard how the particular CMS issue has resolved itself,” said Rachel Ryan, who is general counsel for Dogwood Health Trust. Despite its involvement in the monitoring process, Dogwood has a limited ability to hold HCA accountable.

Some community members in Western North Carolina have grown concerned about the regulatory processes at Mission. It’s unclear what the path forward is — Mission is the only Level 1 trauma center in the region despite these repeated regulatory violations and potential compliance issues. 

“There’s just no real remedy,” said Sen. Julie Mayfield, D-Buncombe. “That is a fundamental underlying problem with the asset purchase agreement, which is one of the most grossly one-sided documents I’ve ever read.”

Mayfield represents Asheville and surrounding areas in the NC Senate and is also the board chair and founder of Reclaim Healthcare WNC, which is a nonprofit that advocates for more equitable healthcare in the region. She said the attorney general has a lot of evidence in the purchase agreement about what the Mission Hospital board wanted from the hospital’s sale seven years ago. 

Attorney General Jeff Jackson now has 30 days from the release of the findings to notify Dogwood if he agrees with the noncompliance findings of the report. From there, either Dogwood or the AG must notify HCA in the ways that Mission may have been found in noncompliance. 

Dogwood will host a virtual Q&A that is open to the public about this year’s compliance findings, 9-10 a.m. on Aug. 4.

Progress on 2023 lawsuit

The attorney general won a crucial argument Tuesday in a yearslong lawsuit against HCA. The lawsuit claims that Mission discontinued certain cancer and trauma services that HCA promised it would continue to provide until 2029, when it bought Mission. The lawsuit also said that this discontinuation of services led to a degradation of care, which would place Mission in noncompliance with the purchase stipulations. 

“HCA threw every argument against the wall to try to get this case thrown out, but they didn’t stick,” Attorney General Jackson said in a press release after the decision. 

The court agreed with the suit’s claim that the HCA purchase agreement “requires HCA to take all steps necessary to actually provide.” NC Business Court Judge Julianna Earp ruled against a summary judgment request by HCA and denied its motion for the exclusion of an expert source on staffing at Mission. She ruled that the case would proceed to trial. 

Now-Gov. Josh Stein originally filed the lawsuit against HCA when he was attorney general in late 2023, alleging that the corporation violated the terms of the purchase agreement by not providing adequate oncology or trauma care at Mission Hospital. There is no timeline yet for when the case will go to trial.

HCA spokesperson Nancy Lindell wrote in an email statement to Carolina Public Press that HCA is “confident” that it is in compliance with the purchase agreement.

“As always, our foremost focus is providing high-quality care to the Western North Carolina communities we are proud to serve, and we remain committed to meeting the healthcare needs of our region,” Lindell wrote in the statement. 

In a separate lawsuit, the city of Brevard sued HCA in 2022 over “monopolistic practices” across healthcare services in Buncombe, Macon, Madison, McDowell, Mitchell, Transylvania and Yancey counties, and a settlement was reached last year.

HCA operates Transylvania Regional Hospital in Brevard, which is the only hospital in Transylvania County. When the suit was settled, HCA agreed to operate the hospital until 2030 and made a number of other commitments to healthcare in the area. 

‘Waiting everybody out’

Though Mission Health operates five acute care hospitals in rural communities outside of its Asheville hospital, Western NC communities rely on the regulation-stricken trauma center.

Maureen Copelof, who is the mayor of Brevard, said staffing shortages or complicated medical procedures will send residents of her community to Mission in Asheville. She said the regional hospital has ended up having fewer and fewer procedures because of this. 

Copelof is also a member of the Reclaim Healthcare board. She said the best path forward is for regulatory agencies to take a stronger stance against Mission and look into solutions like putting an independent administrator in charge of the hospital

“When you look at solutions that have been put in place in the past, they have been ineffective,” Copelof said. 

Because the end of the purchase agreement is just two and a half years away, Mayfield said, Mission is playing the waiting game because they know that Dogwood is unlikely to sue them and the attorney general is unlikely to sue again. She also said there’s no real remedy in sight, even if the AG wins the lawsuit. 

“HCA is just waiting everybody out,” she said.

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