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In Western North Carolina, controversy continues nearly 5 years after HCA Healthcare's $1.5 billion acquisition of non-profit Mission Health in February 2019.

Some 50 physicians from legacy Mission Health facilities about quality of care and corporate culture in an October . As of this week, the total has grown to 130 signatories, Bruce Kelly, MD, a retired family medicine physician who spent decades at Mission Health, told 番茄社区app.

In addition, North Carolina Attorney General Josh Stein has should measures not be taken to comply with certain terms of the purchase agreement. And finally, physicians narrowly that would have prohibited them from speaking out about any alleged concerns.

The moves have coincided with the latest series of public meetings led by Gibbins Advisors, a Nashville, Tennessee-based firm that serves as the independent monitor for HCA Healthcare's compliance with the terms it agreed to when it purchased Mission Health.

During one of those meetings, a signatory read aloud the physicians' letter.

"Many of the for-profit-driven changes that HCA has wrought, despite advocacy and protests from multiple sectors, have gutted the heart and soul of our community healthcare system," the letter stated. "The relationships and deep personal investment that historically mattered to staff across the board have been stifled. Emblematic of this is the loss of over 200 physicians and countless healthcare staff who have left Mission and/or the medical community since the sale." (番茄社区app has previously reported on physician departures in the wake of the deal.)

Though Kelly said the letter's physician signers understand that the healthcare landscape has changed, he added that, "what we don't accept is this ethic of profits over people." The impact of cutting resources, notably in oncology and emergency services, is representative of "what we feel is overall a decline in care, and not just care, but caring," he added.

"We were so very proud of our hospital system here," Kelly told 番茄社区app. "As we say, it was our home on the hill. It was something the entire community was proud of."

Some of the 130 physicians who signed the letter opted to do so anonymously, Kelly said. However, more than half of the letter's current signers are active, practicing physicians, 9 are former chiefs of staff, and 7 are former hospital board members, he said.

Michael Messino, MD, a retired oncologist whose practice split from Mission Health in the middle of 2019, is also one of the letter's signers. He said that, in addition to nurses who have been raising concerns and have even in the wake of the deal, physicians are "standing side by side with them."

However, it's not just physicians and nurses who are sounding the alarm.

In an to Dogwood Health Trust -- the seller representative tasked with enforcing HCA's compliance with obligations to the deal -- Attorney General Josh Stein charged that HCA discontinued certain services that were supposed to remain in effect per the asset purchase agreement (APA).

If HCA remains in violation of the APA for 40 days, the letter states, the Attorney General "reserves the right to take appropriate action."

Several weeks after the doctors' letter was initially issued, Dogwood Health Trust, Gibbins Advisors, and HCA weighed in on where things stand.

Susan Mims, MD, MPH, CEO of Dogwood Health Trust, told 番茄社区app in an emailed statement, "We are grateful to community members who have taken the time to share their concerns and we encourage them to continue to do so. It's only through ongoing dialogue and exchange of information that all of us -- the Attorney General, HCA, and Dogwood -- can move forward to address any issues of potential noncompliance."

"We are in active dialogue with HCA and the Attorney General's office with an eye toward the best resolution for the community," Mims added.

Additionally, legal counsel for HCA has from the Attorney General's office. The response argues that HCA has not breached the APA, has made significant investments in oncology services, and has been prevented from obtaining acute care inpatient beds that would alleviate emergency department wait times. It also argues that the investigative demand is improper.

"We are confident that we have and will continue to meet our commitments under the APA," Nancy Lindell, director of public and media relations for HCA Healthcare's North Carolina Division/Mission Health, told 番茄社区app in an email.

Furthermore, a group of current staff physicians at Mission Health have to the one read at the recent independent monitor meeting, Lindell noted.

"The implications of the letter that suggest we are not giving the best to patients is offensive to those physicians and advanced practice providers who are showing up every day to provide excellent care to our community," the rebuttal letter stated.

Ronald Winters, principal at Gibbins Advisors, told 番茄社区app in an emailed statement that, "We have spoken with physicians associated with the letter ... and also with at least one physician leader who was one of the signers of a letter presenting a different point of view. We are interested in all perspectives and our outreach is intended to encourage the broad community to contact us to help facilitate our work."

Some physicians from legacy Mission Health facilities also have taken issue with proposed bylaws they reportedly felt would hinder their ability to speak publicly about any concerns to practice there. Doctors recently voted against the bylaws, but .

Regarding the bylaws vote, Lindell said, "We are pleased with our physicians' engagement in participating in this process." She added that HCA views the review and approval of bylaws "as a confidential process" and that it cannot comment further at this time.

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