HCAGE | North carotina Healthcare” | Division March 30, 2022 Llogan R. Walters, Esq. Assistant Attorney General North Carolina Department of Justice 9001 Mail Service Center Raleigh, NC 27699-9001 LWalters@NCDOJ.GOV Dear Assistant Attorney General Walters: Thank you for giving Mission Health System (“MHS”) an opportunity to respond to the concerns outlined in your March 16, 2022 letter. MHS is committed to delivering high quality and cost-effective healthcare to all citizens of Wester North Carolina. Consistent with that commitment, MHS remains invested in having an ongoing dialogue with the North Carolina Department of Justice regarding any concerns it has related to MHS. Your letter of March 16, 2022 raised four areas of concern. I have responded generally here to each area of concer, and a more fulsome response on certain topics will follow. 1. THE COST OF HEALTH CARE SERVICES IN WESTERN NORTH CAROLINA First, your letter raised concerns about the cost of health care in Westen North Carolina, It is important to note that the amount a patient pays for the care she receives is impacted by a variety of factors including, but not limited to, insurance coverage, out-of-pocket costs required by insurers which are negotiated by the employer and insurer (not the hospital provider), insurance premium rates, and other factors not set by the prices negotiated between MHS and the insurer. As you know, the federal and state governments dictate what the hospital receives from the Medicare and Medicaid programs along with the patient financially responsible for the care received. MHS is not privy to other providers’ contracts with insurers, and thus, is not able to assess how the reimbursement MHS receives fiom insurers compares to that received by other providers. If you have specific concerns about MHS prices as compared to statewide averages, we would welcome any additional feedback so we can respond specifically. Further, your letter raises concems regarding health insurance premium rates in Western North Carolina as compared to other markets in the state. MHS shares your concerns about the high cost of health insurance generally. To increase competition in the health insurance marketplace in Western North Carolina, MHS contracted with the five largest commercial carriers in the market, an effort intended to ensure access to more cost-effective plan choices in Western North Carolina. Overall, MHS is contracted with nineteen commercial plans. Notably, when HCA purchased MHS in 2019, just one insurer offered plans on the federal health insurance exchange in Western North Carolina. Since that time, MHS has contracted with nine additional federal health insurance exchange carriers. Data on the impact on premiums of this increased competition is available at healthcare.gov, and shows that premiums have decreased since 2020 because of this increased competition, benefitting consumers in Western North Carolina. Thus, please know that MHS has taken substantial, concrete steps to encourage increased competition among health insurers in an effort to drive lower premiums for Western North Carolinians, '50 Schenck Parkway, Asheville NC 28803, HCAhealthcare.comHCAs Healtheare™ Finally, for uninsured or underinsured patients, MHS has implemented and maintained substantial charity and uninsured discount policies, as discussed in my April 30, 2020 letter to General Stein and my July 2, 2021 letter to you. MHS also has a team in place to answer specific billing questions, to help patients navigate their coverage, and to guide patients to programs for which they may be eligible. I, PRICE TRANSPARENCY Second, your letter raises unspecified “allegations” that MHS is not “transparent” about prices. Your letter then acknowledges that your office determined that MHS is compliant with all federal regulations regarding price transparency. In the past, MHS has responded to your specific concerns regarding price transparency, and made adjustments in its practices where warranted. MHS remains open to discussions regarding your specific concerns about price transparency, so please do not hesitate to contact me should any specific concerns arise. Ill, COMMERCIAL INSURANCE CONTRACT PROVISIONS Third, your letter cites unspecified “allegations” that MHS includes in its contracts with commercial insurers certain provisions that limit competition among providers in Western North Carolina, ‘The commercial insurance contracts to which you refer are the product of long-term, arms’-length negotiation, and contain terms that reflect bargained for give-and-take during the course of those negotiations between highly sophisticated parties. As noted above, MHS has undertaken significant efforts to bring more insurers into the marketplace, with significant resulting benefits for patients, who benefit from lower premiums that result from increased competition among health insurers, IV. STAFFING AT MHS FACILITIES Last, your letter raises concerns regarding staffing, cleanliness, and wait times at MHS facilities. A response will follow with additional detail regarding the specific concerns raised in your letter. However, and as discussed in my July 2, 2021 letter to you, MHS is taking a number of concerted steps to address staffing challenges. Further, MHS has received high marks on recent surveys and inspections related to patient safety and quality. Mission Hospital is the only North Carolina hospital with the distinction of being one of Healthgrade’s 50 Best Hospitals in America, an accolade that is based on data regarding clinical quality outcomes. Also, Mission Health recently received an “A” score from The Leapfrog Group (Fall 2021), up from prior scores of “B” (Spring 2020) and “C” (Fall 2019). The Leapfrog Group assesses hospitals for safety and quality, and Mission Hospital is proud to have received an “A” score in the most recent review. In addition, Mission Hospital was the only hospital in Western North Carolina to earn from Healthgrades the Patient Safety Excellence Award, which recognizes hospitals in the top 10% nationally with the lowest occurrences of 14 preventable patient safety events. Mission Hospital also attained a 3-Star rating from the Society of Thoracic Surgeons. Additionally, eight North Carolina DHHS surveys between Jan. 2021 and Feb, 2022 did not substantiate any grievances associated with cleanliness, the most recent Joint Commission survey of MHS found zero patterns or widespread findings related to cleanliness, and the most recent Buncombe County Health Department inspection score was 97. MGS is in the process of collecting information responsive to your specific requests regarding staffing, and will supplement this response with additional information in the coming weeks.HCAs* Healtheare™ We hope this information reassures you that MHS remains as committed as ever to providing cost- effective, high-quality healthcare to the citizens and communities of Western North Carolina. We are of course happy to engage with your office in a broader discussion about these matters at any time. Sincerely yours, wrolina Division HCA Healtheare