WNC Hospital Draws Criticism For Care, Labor Practices After Shift To For-Profit Model

This conversation originally aired in the June 22, 2025 episode of Inside Appalachia.

People in rural areas across the U.S. are struggling to access the health care they need. Rural hospitals are closing at alarming rates, and some that remain open offer limited services. 

In Asheville, North Carolina, Mission Hospital serves the metro area and its surrounding rural counties. But in recent years, the hospital has been scrutinized, and even federally investigated, for a range of problems. 

Andrew Jones has been covering Mission Hospital for the Asheville Watchdog. He spoke with Inside Appalachia Host Mason Adams.

This conversation has been lightly edited for clarity.

Adams: You’ve covered multiple stories for the Asheville Watchdog about troubles at Mission Hospital. For listeners who may not be familiar, can you describe what Mission Hospital is, and the role it plays in health care in western North Carolina?

Jones: Mission Hospital is part of the Mission Health System, and famously, right now, it is also part of HCA Healthcare, which is the largest hospital owner in the United States and one of the largest hospital owners in the world. And Mission Health, the system here, which is comprised of six hospitals, was bought by HCA Healthcare in 2019 for $1.5 billion. Significantly, it shifted from a nonprofit hospital system to a for-profit hospital system. It was not a perfect nonprofit hospital system before the purchase, but there have been so many frustrations with how the system has been run since the purchase that people wholeheartedly believe that a for-profit system is one that is more deleterious to our community than it is helpful. 

Adams: What led to that sale in 2019?

Jones: There are a host of reasons, and I think when we talk about exactly why it was sold, a lot of it comes down to discussions about finances. There were flags for years that said that the nonprofit model wasn’t going to be one that was going to be sustainable long-term for this community that is a growing community with an evolving set of needs in care. The then-CEO, Ron Paulus, started to speak to the board and speak to the community and speak to potential buyers about the possibility of selling the system and making sure that it was stable permanently financially. That’s really what led up to the sale to HCA.

Now there’s a caveat here, and that is essentially in that there are questions about whether it really was a struggling financial system, whether it was as dire as Paulus was making it out to be and specifically making it out to be to the board of the Mission Health System, who ultimately made the decision to sell it to HCA. We do have data about how much profit the hospital has made since the sale, and we can say that it was definitely successful. If you’re thinking in terms of profits, the hospital was profitable by many, many more millions, at least $100 million more after the HCA purchase and after [the] COVID-19 [pandemic]. And so, the for-profit system is definitely working, but I think the question for this community is, who is it working for at this point?

Adams: It seems like there’s been a drum beat of stories about problems at Mission since that sale in 2019, beginning with patient care. What’s going on?

Jones: I have covered everything from patients who have died, to patients who have received poor care, to patients who have not received care in a timely manner. Some of these cases have been noted not only in the press, but also in formal investigations into this hospital.

For instance, we ran a story in late 2023 calling out the fact that Mission’s ER [emergency room] system had become sloppy, and that nurses were not being given the opportunity to call report as they were transporting patients from the ER up to floors, and they began to send complaints to the U.S. Department of Justice and Health and Human Services. We ran that story, and right after I ran that story, I got a call that said investigators from the Joint Commission, which accredits Mission Hospital, were calling nurses and asking what was happening.

And then a few weeks later, I got a call that said the state was at the hospital investigating. And then a few weeks later, I got another call that said that the federal government was at the hospital investigating. And long story short, that investigation that those entities — it was just the state and [Centers for Medicare & Medicaid Services] — found that over two years from 2021 to 2023, 18 patients had been harmed as a result of violations of federal standards of care. Four of those 18 people had died in or around the emergency department because of issues there. And if you read that report, which was some 384 pages long, it put the hospital in immediate jeopardy, which is the most severe consequence any hospital can face.

It means that CMS can essentially suspend funding from them because of how poor the patient care was. [When] you read that report, it really does sound like health care reporters are making dire mistakes here, but what we found in further investigations is that a lot of it is down to lack of staff. And if there’s a lack of staff, it’s essentially on administration or management, because they are responsible for not only hiring folks, but making sure that the environment in which health care workers are doing their duties is one that they want to stay in. And so, we have found not only that there’s been a flight of nurses, but there’s also been a flight of doctors from this region after the HCA purchase. That is essentially down to the fact that they are frustrated with the way that they are being treated as employees of the HCA Healthcare system.

To put a number on that, 660 nurses departed Mission between 2022 and 2023, and more than 200 doctors departed after the sale, according to our reporting. And so, it’s a hospital that needs more staff, but whose administration is not doing everything that it can to make sure that staff is there, that they’re well paid, and that they feel that they can lead sustainable lives in one of the most expensive counties in North Carolina and the most expensive county in western North Carolina.

Adams: So this hospital system is struggling with patient issues. It’s struggling with workforce and labor issues. What does all this mean for the people who live around metro Asheville that rely upon these medical facilities?

Jones: There are around a million folks who use this system, and what this means for them is that they cannot feel a sense of guarantee that they will get the best health care possible when they enter this system. And for our rural friends and neighbors and our neighbors in other counties, Asheville is definitely important in western North Carolina, but it is not the most important county. We have so many friends and neighbors in adjacent counties and in counties that are having to come to this region to get care because — and this is now talking about a national situation — hospital care in rural communities and in less densely populated communities is beginning to evaporate, and it’s beginning to be concentrated in these urban areas. So people are forced to come here to Asheville, and in many cases, they’re sent to a regional Mission Health facility, and then they are ported down here to Mission [Hospital] because it offers such a wide variety of services.

I want to be clear about that — there are so many wonderful, amazing doctors and nurses here, some of the best in the world. They are professionals at what they do, and I know so many of them. I’ve seen many of them work, and it’s so impressive and the care here is incredibly diverse, but the problem is that with a strained and a strapped staff, there is not really a guarantee that if you come to the emergency department here that you are going to be 100% completely safe. That worries people, and they want other options, and they seek other options, and some of them have decided to move. Not everybody has the financial feasibility to do that.

Some of them have decided to choose other hospitals in the region, like Advent Health or Pardee. Some of them have decided to go to Charlotte or even to the Triangle area to get services. One of the stories that we published recently talked about a man who came to the emergency room with heart issues, went into a bathroom before getting an echocardiogram, started to have an intensification of those heart issues, [and] pulled the cord in the bathroom for help. Nobody came, and essentially, his heart arrested and stopped. For those of us who are just laymen, essentially, he died once and then was taken and there was an attempted resuscitation, and he died again the next day, just because the emergency room was so packed that night, and nobody could make it to that bell.

When people read things like that, or if they experience things like that, what they’re concerned about is, “Am I going to be safe in a place that is meant to be the safest place in the region?” I guess, as both a journalist and as a human being, I never want anybody questioning that. I want the hospital that my friends and neighbors visit to be the safest place in the city for them, and when you have a for-profit institution that is not working on guaranteeing that, you create a sense of apprehension — and in this case, that sense of apprehension applies to a million people.

Adams: I felt like this story was important to bring on and talk about on Inside Appalachia, because it’s an especially acute version of a story that’s affecting hospital systems across the region, and really across America. As a reporter who’s covered this health care system up close, what’s the outlook for Mission Hospital?

Jones: As a journalist, I have to be optimistic, because if I began to believe that my amplification of voices couldn’t make any change, then I couldn’t do my work with the rigor that I tried to do it. I am hopeful that they will be better. I am hopeful that more staff will be hired, and I’m hopeful that they will be paid more. I’m hopeful that the administration will listen to nurses and doctors as they construct efficient and healthy and progressive systems to meet the needs of western North Carolinians, whether they are old, whether they are young, whether they are middle-aged, whether they have immediate emergent needs, or whether they have long-term care needs.

If I am honest about what I have seen, the trend is that there is pushback on this hospital, and there is maybe a glimmer of what change could look like. And then there is a settling back into old ways. I have seen the attorney general file a lawsuit against this company. I have seen a federal investigation. I have seen them denied the option to expand their facilities by the state of North Carolina. I have seen community pushback like I’ve never seen before in the U.S. against a single hospital system. And I still had to report a few months ago that somebody died in the bathroom, and that can be frustrating. The hopeful part about all of that is that this community will not take no for an answer, and they will continue to push back. Nurses are protesting. I will continue to investigate and to run stories that look deeply into the systemic issues here, and we’ll continue to do that until North Carolinians get better health care in this region.

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For more reporting about Mission Health, visit the Asheville Watchdog.