October 19, 2023

Mr. Ronald Winters, Independent Monitor

Gibbons Advisors
1900 Church St STE 300
Nashville, TN 37203

Re: HCA Healthcare and Mission Health System

Dear Mr. Winters:

It has been a tumultuous four years and eight months since the sale of Mission Health System to
HCA. We anticipated the transition would be challenging given the complexities when large
organizations shift from nonprofit to publicly traded, for-profit status.

What we did not anticipate was how devastating this transition would be to our community, nor the
marked impact it would have on the foundational issue of quality care in our region.

As physicians with long histories of living in and serving western North Carolina, we can attest that
our healthcare system has been a backbone of this community for decades. As contentious as it
was, the 1998 merger of Mission and St. Joseph’s was accomplished in good faith, with unified
purpose, and with meaningful physician involvement. We were committed to honoring shared
values. Collaborative relationships, despite disagreements, were maintained for the greater good.

In effecting that merger, there was no wavering in the support for the highest quality medical care
possible for all residents of western North Carolina. It was what this community and our physician
staff stood for. We were proud of our system and, despite its imperfections, we could defend it and
advocate in meaningful ways for sustained, continued improvement.

Our commitment was not only to quality of care, but also to a quality of caring. Relationships
mattered, collegiality mattered, respect mattered. The culture built by thousands across all the
hospital services mattered. It was a given that the value of a personal touch during a hospital stay
or procedure mattered.

A marker of this quality is that patients remember how you make them feel as much as what you
say or do.

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
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.

It is difficult, if not impossible, for members of the community to speak with pride about the hospital
that has been our healthcare home on the hill. It feels like a rental now, the landlord impervious to
calls for needed improvements.

Profits over people is not an ethic, model, or aspiration that can deliver the quality of care we all
expect and deserve. We can accept this, or we can work towards a collective physician voice to hold
HCA accountable. This letter is the initial step in bringing together physicians in our region to
address the changes needed to support the excellence of care we know is possible. We will also
reach out to our allied professional colleagues and other committed stakeholders. We share a
common cause and commitment.

We join the chorus of advocates in asking for the relationships and resources needed for the
medical staff, all staff, to function at their highest ability. We ask that hospital leadership look at
economics as if people mattered. With our many hundreds of years on the front line of patient care,
we know what a fully resourced system looks like. We don’t see it now.

In tandem with this letter, we are compiling a list of specific concerns and opportunities for the
reinvestment we believe is necessary to restore the culture and quality that previously defined our
healthcare system. We will share that list with you when it is complete and ask that you factor it into
your analysis.

We welcome meaningful engagement with national and local HCA leadership. To date we have seen
little to no interest on their part in working with physicians or community leaders across multiple
sectors to address quality-related problems. We implore HCA leadership to demonstrate
substantive collaboration to address the crisis of relationships and resources. We will be forthright
and transparent, and we respectfully request the same from HCA.

We do not have to accept the gutting of what has mattered, nor accept the loss of the heart and
soul of our healthcare system. It is beyond disappointing that quality of care is not in the purview of
the Independent Monitor. We, along with others committed to this issue, will continue to hold that
banner front and center.

In closing, it is extremely distressing - and in fact unconscionable - that many physicians believe
they cannot express their concerns publicly for fear of retribution from HCA. That fear and the
overall sense of intimidation is widespread. Stifling the ability to speak freely undercuts the
communication necessary for shared trust, continued improvement, and a greater good. That ability
is central to the integrity of the medical profession and is essential to patient lives and patient care.
We will continue to find ways for physicians' voices to be heard. We, the undersigned, reflecting
physician leadership in our community, go on record here representing those voices, named and
anonymous. We are the tip of the iceberg.

Sincerely,

David Baldwin MD Emergency Medicine

Clay Ballantine MD Internal Medicine
David Bate MD Family Medicine
Alan Baumgarten MD Family Medicine
Tom Berner MD Emergency Medicine
Denniston Crews MD Nephrology
Jim Cummings MD Internal Medicine
Miles Elmore MD Nephrology
Brian England MD Nephrology
Michael Frisch MD Orthopedic Trauma Surgery
Tim Gallagher MD Radiology
Peter Gentling MD General Surgery
Mark Helms MD Emergency Medicine
Randall Johnson MD General Surgery
Scott Joslin MD Internal Medicine
Henri Kieffer MD Radiology
Bruce Kelly MD Family Medicine
Robert Kline MD Family Medicine
Alan Krueger MD Psychiatry
James Ladd MD Internal Medicine
Allen Lalor MD Emergency Medicine
Lauren Livingston MD Family Medicine
Bill McKenna MD Infectious Disease
Peter Mangone MD Orthopedics
David May MD Gastroenterology
Mark McNeill MD Family Medicine
Mike Messino MD Hematology / Oncology
Martin Palmeri MD, MBA Hematology / Oncology
James Powell II MD Otolaryngology
Charlie Rowe MD Radiology
John Russell MD Cardiology
Martha Salyers MD, MPH Family Medicine and Public Health
Lary Schulhof MD Neurosurgery
David Serfas MD Cardiology
Jon Silver MD Neurosurgery
Ellison Smith, MD Rheumatology
David H. Troxler MD Palliative Care
Joel Rosenberg MD Internal Medicine
Mike Weizman MD Family Medicine
Win Word-Sims MD Nephrology

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For comments or questions or to add your name to this effort, contact

Bruce Kelly, MD
828-423-6037
brucekelly52@gmail.com

Allen Lalor, MD
828-776-5668
allen.lalor@gmail.com