HCA is the largest and wealthiest for-profit hospital company in the world – and acts like it.
HCA Healthcare is the largest and richest for-profit hospital corporation in the world. With 182 hospitals throughout the United States and United Kingdom, HCA pulls in more than $51 billion in revenue each year. The company consistently posts annual profits in the billions of dollars, and has enjoyed nearly 100 percent growth in both revenue and net income over the past decade. HCA shareholders have seen big returns on their investments, with share prices growing more than 600 percent since 2010.
The secret to HCA’s success is simple. The company charges more and delivers less to patients. HCA achieves this through a strategy of vertical and horizontal market domination — using mergers and acquisitions to cherry-pick dependably high-paying patient populations on the front end, while building a massive cost-cutting machine on the back end to control costs of labor and supplies.
The result is that, in communities across the country, HCA has wreaked havoc — cutting out its competition to increase prices, cut staffing, and slash critical services.
Four things stand out about HCA when compared to other major hospital systems: its size, its profits, its lean operations, and its prices. This isn’t coincidental — it is all a part of HCA’s national playbook.
Time and again, HCA has gobbled up their competitors to become a region’s dominant health care provider, giving HCA free reign to jack up prices and slash services to maximize their profits. After HCA takes over a market, it shutters specialty services at less profitable hospitals and may even eliminate its primary care services completely — turning the facilities into feeders to send patients to their flagship facilities.
HCA hunts for opportunities to become the number one hospital provider in a market, particularly in wealthier areas where patients have higher levels of private insurance, which typically reimburses hospitals at far higher rates than Medicare or Medicaid.
Since 2013, HCA has acquired at least 26 hospitals, becoming the number one operator in at least three markets in the process. In some instances, like in the Savannah, Georgia and Nashville, Tennessee markets, HCA acquired multiple hospitals over the course of several years, garnering market power over time. Almost all of HCA’s new acquisitions are in the high-growth Sun Belt, where HCA has established itself as the region’s dominant hospital operator.
Across the country, HCA is the number one operator in twenty health care markets. The hospital giant controls at least half the market in seven markets, including 69 percent of all discharges in Panama City, Florida, 58 percent in Asheville, North Carolina, and 52 percent in Austin, Texas.
Of HCA’s over 176 hospitals throughout the United States, 55 are among the nation’s 100 most expensive. HCA’s Poinciana Medical Center in Kissimmee, FL, for example, charges over 18 times the cost of care, giving it the distinction as the most expensive hospital in the nation. In comparison, the national average is four times the cost of care.
When companies like HCA succeed in becoming a community’s dominant health care provider, they can demand bigger payments from health insurance companies. So it’s no surprise that HCA, the biggest for-profit hospital chain in the country, has the highest charges for patient care in 77 percent of the regional markets they operate in, as seen in the map below.
After establishing itself as a community’s main provider, HCA has demonstrated a longstanding pattern of cutting services, eliminating choices, and leaving vulnerable patients at risk. Unfortunately, these cuts only escalated during the pandemic.
Part of the formula for securing bigger dividends for HCA’s Wall Street shareholders is giving its patients less for their money. That is why, following HCA’s acquisition of a community’s existing hospital system, residents soon learn that fewer services are available at their local hospital than before.
Following the sale of Mission Health in Asheville, NC to HCA in 2019, HCA received nationwide scorn for its treatment of patients and the surrounding community. Longtime patients experienced increased costs, surprise bills, and elimination of vital services.
Rural communities and communities of color are particularly vulnerable to service cuts to enhance HCA profits — even when the company enjoys profitability in the region. Since 2014, HCA eliminated inpatient services at least four hospitals, converting inpatient services into freestanding emergency rooms. Freestanding emergency rooms generally provide care akin to urgent care, but regularly charge hospital emergency room prices for their services.
What happened in rural Jasper, Tennessee, is illustrative. After acquiring Grandview Medical Center, in 2014, and adding it to the corporation’s Parkridge Health System, HCA shut down all inpatient services and converted the facility to a freestanding emergency department. Now, emergency patients requiring hospitalization are transferred to Chattanooga, 30 miles away.
Similar stories come out of communities large and small across the country. Within two years of its 2017 purchase of Cypress Fairbanks Medical Center in Houston, Texas — making HCA the leading provider in the country’s fourth largest city — nearly 600 health staff were laid off when the hospital became a freestanding ER.
Meanwhile, following HCA’s 2020 acquisition of Shands Live Oak and Shands Starke hospitals in North Florida, it ended all non-emergency and inpatient services at both facilities, and turned them into freestanding ERs. Each one is now affiliated with an HCA hospital more than 20 miles away. The mayor of Live Oak, Florida, described the move as a “gut punch” to the city for its impact on patients and employees. In 2021, HCA closed another hospital in South Florida, turning it into a freestanding ER.
Since 2020, HCA has shuttered, or plans to, at least four labor and delivery departments. In August of 2022, HCA announced the closing of the labor and delivery department at Frisbie Memorial Hospital in Rochester, New Hampshire. When HCA acquired the hospital in 2020, they signed an agreement to continue labor and delivery services for at least five years. In Northern Virginia, HCA announced it is closing a NICU in a low-income neighborhood in November 2022.
In addition to dramatically raising prices, HCA’s market dominance enhances its ability to extract cash from patients and their insurers in other ways. HCA employs a variety of aggressive billing tactics, ranging from surprise billing patients to exorbitant trauma fees. HCA has made it clear: patient care is a money grab opportunity.
Over the past decade, HCA has come under fire for their exploitive trauma team activation fees. Trauma patients are typically those severely injured in a serious accident or have suffered a gunshot wound. However, according to research by Kaiser Health News, HCA liberally activates the fees for more minor injuries and HCA’s activation fees run as high as “$50,000 per patient and are sometimes 10 times greater than those at other hospitals.” These fees are part of a long practiced scheme by HCA. Back in 2014, the Tampa Bay Times reported that patients who went through an HCA hospital for trauma care had an average bill of almost $125,000, or $40,000 more than other trauma centers in the state.
HCA starts its bills collection before patients even leave the hospital. Nurses report seeing patients dehumanized while facing potentially dire health outcomes. One nurse at HCA’s Mission Health in Asheville, North Carolina, saw an HCA collections agent come to an elderly man at his sick wife’s bedside, serving him with a $12,000 check for his wife’s medical care.
In a complaint to the North Carolina Attorney General, a Mission Health patient shared their experience of a HCA bill collectors harassing them during their recovery:
“HCA should not be allowed to do this to patients while in the hospital before insurance etc. has been filed. They are taking advantage of people at their worst time — while they are sick and in the hospital.” — comment from NNU’s 2022 FOIA request of public complaints about HCA’s Mission Health to North Carolina Attorney General Josh Stein’s office
HCA not only has some of the most expensive health care in the nation, but also routinely sues patients who are unable to pay. Over the last decade, HCA’s debt collection subsidiary Medicredit has filed medical debt collection lawsuits against almost 8,000 Colorado patients.
In recent years, outsourced private equity owned emergency staffing firms have come under fire for their deceptive surprise billing practices. Envision Healthcare, owned by Kohlberg Kravis Robert (KKR) and Team Health, owned by the Blackstone Group, have faced multiple lawsuits and federal inquiries for billing out-of-network rates to patients for emergency medical services. HCA has broad partnerships with both companies. NNU’s analysis finds around half of HCA’s emergency rooms are staffed by Envision or Team Health.
HCA has also come under fire from patients and government officials for charging undisclosed additional fees. In 2019, patients in Florida sued HCA over undisclosed “surcharge” fees. In 2020, North Carolina Attorney General Josh Stein wrote a letter to HCA demanding an explanation for new “outpatient fees” appearing on the bills of Mission Health patients who had simply gone to see their primary care provider.
In Asheville, North Carolina, HCA’s opportunistic behavior since acquiring Mission Health in 2019 has become a national story. Community members, public officials, and health care workers have sounded the alarm of HCA’s gutting of vital health care services and rising cost of care.
One Mission nurse described it as HCA taking a “hatchet” to the community’s only health care system—eliminating primary care clinics and wheelchair and seating clinics, along with reducing charity care and rural cancer services. These cuts have left thousands of residents without local access to needed care, forcing patients to travel miles to receive services.
HCA’s imposition of cut and short staffing has led to an exodus of nurses, with 15 nurses leaving the trauma care unit in 2020 alone. The staffing crisis goes beyond nursing. Amid clinic closures and aggressive attempts to renegotiate contracts with physician groups, ABC News 13 in Asheville reported that at least 79 doctors have left or plan to leave Mission Health.
The Asheville community has come together to organize against HCA’s profit-first behavior—holding forums, rallies, and writing hundreds of complaints to North Carolina Attorney General Josh Stein, demanding HCA be held accountable.
In September 2020, nurses at HCA’s Mission Health voted in huge margins to form a union, the largest victory at a non-union hospital in the South since 1975. This victory came despite a fervent anti-union campaign, where HCA spent $400/hour on an anti-union firm, according to The Intercept.
In August 2021, a group of Asheville residents filed a class action antitrust lawsuit against the system, accusing HCA of engaging in anticompetitive tactics, resulting in higher prices and lower quality care for patients. In 2022, two more antitrust lawsuits were filed against HCA over the Mission acquisition. These cases are still ongoing and we will provide updates on this website.
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HCA has been caught time and again in systematic efforts to defraud government health care programs for profit and at the expense of patient care, calling into question the stability of the company culture and leadership.
Disturbingly, many of these allegations predicate on taking advantage of seniors who are enrolled in Medicare. On multiple occasions, HCA and other hospitals have paid ten of millions of dollars to settle claims that they perform medically unnecessary procedures on our nation’s seniors to extract more money from the federal government.
FBI agents descended upon HCA hospitals across the country as part of a nationwide investigation of HCA systematically defrauding Medicare and paying kickbacks to doctors to steer patients to its facilities. The result of this investigation: HCA was found guilty of defrauding the U.S. government and required to pay$1.7 billion in restitution.
An alarmingly large number of cardiac stents were implanted in patients in a Florida hospital under HCA ownership. An internal review found that more than 43 percent of the procedures were outside “reasonable and expected medical practice.”
An internal whistleblower revealed that over the course of eight years, more than 1,200 procedures in another Florida facility were considered medically unnecessary; These treatments took place exclusively in the hospital’s catheterization laboratory, which suspiciously accounted for about 35 percent of the hospital’s profits.
HCA’s Chattanooga-based hospital allegedly gave financial benefits to a physicians group that referred patients to HCA-owned facilities. HCA paid $16.5 million to the Department of Justice to settle the allegations.
Hospitals across the country settled a total of $34 million with the Department of Justice for alleged unnecessary spine procedures related to osteoporosis — not only defrauding the federal government, but also targeting more vulnerable senior populations. Despite HCA only accounting for around 4 percent of all hospitals in the United States, 20 percent of these fraud cases occurred at HCA facilities.
The United States and the State of Florida contended that HCA hospitals in Florida administered unnecessary testing and double-billing to Medicare for fetal testing at four separate HCA hospitals in Florida. These alleged violations of the False Claims Act resulted in a $2 million payout by HCA.
Nationwide, 457 hospitals were accused of implanting cardiac devices in Medicare patients in violation of Medicare coverage requirements. A whopping 42 HCA hospitals were implicated in the scheme, making up over 9 percent of all cases. Accordingly, HCA paid the largest settlement of all the hospitals to resolve these claims.
Four Texas-based HCA hospitals were paid kickbacks from several emergency transportation providers in exchange for Medicare and Medicaid referrals. This practice, a direct violation of the Anti-Kickback Statute, resulted in the four hospitals paying $8.6 million to resolve the allegations brought against them.
A former nurse at San Jose HCA hospital accused the system of ER billing fraud.
After a routine audit of a Las Vegas based HCA hospital, HHS discovered the hospital incorrectly billed Medicare patients. HHS has told HCA to refund it $23.6 million in Medicare overpayments to settle the investigation. The full report of the investigation is available here: https://www.oig.hhs.gov/oas/reports/region4/41908075.pdf These proceedings are ongoing.
Over 20 lawsuits have been filed against HCA after the private information of 11 million patients were posted on an online forum after a data breach. Patients’ names, cities, states, zip codes, email addresses, phone numbers, dates of birth, genders and appointment information were made public.
A recently unsealed lawsuit alleges HCA Healthcare and its medical staffing company partner, Team Health, backed by private equity giant Blackstone Group, are overcharging patients.
In late June, nearly 2000 nurses at three Ascension hospitals in Texas and Kansas held the largest nurses’ strike in both states’ histories, protesting the Catholic health care giant’s unsafe staffing practices.