(Bloomberg) Dale Collier had never attended medical school. However, as a nurse practitioner, she was empowered to oversee patient care the same way medical doctors do. She was assigned to the overnight shift at Chippenham Hospital, a facility with more than 460 beds in Richmond, Virginia, where workers say staffing is light and pressure on providers is intense.
Chippenham is owned by HCA Healthcare Inc., the $84 billion company that runs America’s largest hospital chain. Like a growing number of hospitals across the country, HCA has begun placing NPs in higher-stakes roles. For Collier, who had an acute-care license, that meant tackling some of Chippenham’s sickest patients.
It proved too much for her. Virginia regulators later found that patients died after she failed to properly care for them. In January 2022, a 69-year-old man with rapidly dropping blood pressure suffered what was likely a gastrointestinal bleed after she failed to assess him and order testing. In March of that year, Collier gave an agitated woman three doses of a medication that wasn’t recommended for her condition, then another drug, until she became unconscious. Collier didn’t complete a bedside evaluation or consult a physician. The patient died two days later.
Less than a decade ago, almost everyone with Collier’s responsibilities at Chippenham was a medical doctor, rather than a nurse with an advanced degree. At the time of the deaths, NPs like Collier made up a fifth of such staff, one former HCA physician estimated, as the company’s hospitals came to operate with some of the nation’s most razor-thin staffing levels. In effect, she was part of an industry experiment testing whether nurse practitioners can do a physician’s job caring for acutely ill patients. The experiment failed.
After the deaths, a Chippenham supervisor told Virginia investigators the hospital recognized it had a problem and had fixed it. “The hospital no longer hires new graduates onto the night shift” because of “the level of independence required,” according to the state’s final order in her case. But Virginia regulators say they can’t confirm any such change was implemented. Staff who spoke to Bloomberg Businessweek say it never was at Chippenham—or at scores of other HCA facilities across the country—an assertion the company did not dispute.
HCA spokesman Harlow Sumerford said the company uses NPs “to supplement, not replace, physician-led care teams in hospitals” because of a nationwide doctor shortage. He said its “use of properly trained and licensed NPs is appropriate; they are supervised by physicians who are available for consultation.” Chippenham and its sister facilities in Richmond have received “many quality accolades,” Sumerford said.
Far from an aberration, the circumstances in which Collier was operating are emblematic of a sea change in America’s hospitals, where the number of NPs, and the amount of responsibility they’re asked to shoulder, is rapidly growing. Businessweek previously revealed widespread problems in how nurse practitioners are trained. Unlike education for medical doctors, NP instruction isn’t standardized, and the clinical hours that are central to an NP’s training—already a fraction of those completed by physicians—are largely unregulated. That means hospitals can’t count on NPs being ready to practice after graduation, the Businessweek investigation found.
In at least one important way, hospitals have little choice: They need more providers to handle growing demands for health care. Physicians are in short supply, and NPs can fill the gap. There’s also a financial motivation. A primary care physician costs $344,308 a year, whereas a primary care NP costs about $156,546, according to 2022 data compiled by Kaufman Hall, a healthcare consulting company. Yet primary care NPs can generate $424,979 of direct revenue a year, only $37,000 less than a physician. Put another way, NPs are twice as profitable.
HCA Staffs More Leanly Than Many US Health Systems
Source: Agency for Healthcare Research and Quality’s Compendium of US Health Systems, 2022
Note: Includes hospitals with at least 20 nurse practitioners and at least 25 beds
By one measure, HCA reflects the industry at large. It staffs about 37 NPs for every 100 physicians, slightly more than the typical US healthcare system, based on a Businessweek review of data compiled by the US Department of Health and Human Services.
But NPs who join HCA are at a particular disadvantage: They work in a system so thinly staffed that there’s little margin for error. The company has one of the lowest ratios of physicians and advanced practice providers (a catchall term for nurse practitioners and physician assistants) per bed among more than 600 US healthcare systems that the federal government tracks. Registered nurses and other support staff aren’t included in that tally, but other government data that accounts for a wide range of roles also show HCA tends to staff leanly. It’s one reason HCA is widely regarded as one of the most efficient operators in its industry, with the largest profit margins of any American hospital chain that trades on the stock market. Shares have returned fivefold in the past decade, even after falling recently amid concerns about reduced Affordable Care Act subsidies.
HCA Staffing Shrank During Pandemic, Unlike Most Hospitals
The hospital chain’s profitability outperformed peers as one measure of staffing fell from 2018 levels
Source: Bloomberg Businessweek analysis of data from the National Academy for State Health Policy’s Hospital Cost Tool and AHRQ Compendium 2022
Note: Data for other hospitals represents the median values. Includes hospitals with consistent ownership from 2018 through 2022. Care providers are measured as full-time equivalent workers who provide direct patient care. Patients are measured as adjusted discharges.
HCA disputes the government’s staffing data, saying it undercounts the company’s physician population by two-thirds because of “flawed calculations that drastically misrepresent the number of physicians that work in our hospitals daily.” A spokeswoman for the federal Health Department said the government counts only doctors who are “closely affiliated” with hospital systems, to give the most accurate measure of physicians who physically practice within them. That methodology was applied to all health systems the government analyzed.
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Some HCA staff say the company is merely going where the data is taking it—a future with fewer medical doctors. This trend has been evident for years in primary care: Fewer physicians are pursuing it, and NPs have filled that role for many Americans. HCA staff who spoke to Businessweek said that the shift is now underway in other practice settings. In many of them, “we will get to a point where there will be no physicians left,” says one executive who recently left HCA after several years at its Nashville headquarters and asked for anonymity to speak on the sensitive topic. “You just won’t have physician oversight, because we won’t have the supply.”
Scott Hickey, a physician who ran Chippenham’s ER for a decade until 2019, says he constantly had to resist management’s push for minimal staffing levels. “You put in these inexperienced, not-as-well-trained, midlevel clinicians and have them responsible for an entire intensive care unit overnight,” Hickey says. “And that’s a disaster.”
The Hospital Corp. of America was co-founded by Dr. Thomas Frist Sr. more than a half-century ago in Nashville. Frist, a cardiologist and internist, complained he had trouble getting his patients into nearby hospitals, so he opened his first for-profit hospital, a squat, five-story facility called Park View, as a remedy.
Frist’s son Thomas Jr. saw the power in economies of scale, and the company started gobbling up more facilities. American health care has been bending Frist’s way ever since, and HCA’s value has soared. Thomas Jr. has become the world’s 56th-richest man, with a $30 billion fortune largely derived from his HCA shares. His younger brother, Bill, became majority leader in the US Senate, where he helped pass the Medicare Modernization Act of 2003, allowing retirees to receive benefits through private insurers.
The company’s gravitational pull has turned Nashville into the world’s unofficial headquarters of for-profit health care, drawing more than 900 companies to the area. Its own holdings have exploded, too, with more than 180 hospitals across several states, and a toehold in the UK.
Within that portfolio, Chippenham and its affiliated facilities are a powerhouse, the company’s fifth-largest by revenue, federal data show. Closely watched from corporate headquarters, Chippenham executives have frequently been plucked for bigger roles, charged with running dozens of hospitals in HCA’s system.
Half of HCA Hospitals Are in Florida and Texas
At least 1.9 million patients were treated and discharged across its network of more than 180 hospitals in 2022
Source: Agency for Healthcare Research and Quality’s Compendium of US Health Systems
Note: One HCA hospital in Alaska is not shown
Big revenue doesn’t necessarily mean big resources. In Richmond, Chippenham’s emergency room has a troubling reputation. Current and former employees describe limited staffing and resources that guarantee they’ll be caring for patients in hall beds and in the waiting room on a nightly basis. Patients describe waits stretching for several hours amid blood smears and vomit bags.
All emergency rooms can become hectic, of course, and during the Covid-19 pandemic some reached levels of disorder from which they haven’t recovered. But traveling nurses who have worked at several facilities told Businessweek that Chippenham stands out for its chaos and lack of resources and staff. Nurses in the hospital’s intensive care units describe getting “tripled” multiple times a week—being responsible for three patients at a time. The standard is two, according to the federal Centers for Medicare and Medicaid Services. Tripling happens when staffing is insufficient to match the patient population. Some of the nurses said they’d worked at nonprofit facilities that never tripled them.
The problems were so well known that even some community members were wary. Debbie Clendenin, a longtime Richmond resident, says she was anxious when she found out her father would recover from his knee surgery at Chippenham. “If I had something come up for me, I’m not going to Chippenham,” she says.
Clendenin vividly recalls Dec. 4, 2020, her last night with her father. At 87 and suffering from chronic obstructive pulmonary disease, or COPD, Calvin Koch wasn’t in peak health, but his knee surgery had been a success and he was expected to recover without incident. Still, he didn’t want Clendenin to leave him alone. She reminded him the surgery had gone well and encouraged him to eat his dinner. “I know that when I left him at 6 o’clock that night, he was fine. There were no indications that we would have a problem.” Clendenin said goodbye, and when she told him she’d be taking him home the next day, she meant it.
Koch wouldn’t see the sun rise. When Clendenin got a call from hospital staff the next morning, she was told he’d simply succumbed to COPD. Given his age, Clendenin had no reason to doubt them.
According to allegations filed by Virginia’s Committee of the Joint Boards of Nursing and Medicine, though, a massive and avoidable lapse in care preceded Koch’s death.
Throughout the day, Koch had been seen by two physicians, a vascular surgeon and a pulmonologist, according to HCA’s spokesman. But as the day wound down, his care fell to Collier, who had previously worked as a registered nurse without any publicly documented disciplinary issues. As an NP, she would have to carry weightier responsibilities.
According to the allegations, Koch’s problems started when his blood oxygen dropped, reaching 89%, the low end of what’s safe for people with his respiratory disease. He began pulling at his oxygen mask.
As Koch grew agitated, Collier consulted with her manager, another NP, according to the state’s allegations. The two agreed that Koch should be moved to another floor and have his arterial blood gas tested, which would help determine their next course of action. But Collier never had him tested, state investigators alleged. Later, she would tell the investigators that she often received 40-pager alerts a night and didn’t always document changes in patients’ conditions. Koch was alive when Collier’s shift ended at 7 p.m. Overnight, his blood oxygen continued to drop, and he went into respiratory and cardiac arrest. Hospital staff couldn’t revive him. He died at 4:03 a.m.
Koch was the first of four patients to die over two years after being cared for by Collier, according to the state allegations. HCA never told his family the state had raised concerns about his death. Clendenin didn’t learn of the allegations until Businessweek reporters connected details from the state filing with details in Koch’s obituary.
“I felt guilty, because he begged me not to leave him, and I did, so I had to live with that,” Clendenin says. “I didn’t know all this. And if I knew how to go about it, I too would look into it because I’d be afraid of it happening to someone else.”
Chippenham put Collier on a performance improvement plan after the first three alleged patient deaths and terminated her in April 2022 after the fourth.
Collier hired an attorney to represent her before a committee of Virginia’s Boards of Medicine and Nursing. The final “findings of fact” documented the allegations in two of the patient deaths, while dropping mention of two others, including Koch’s. Deliberations over her fate took place at an informal conference; no transcripts of the discussions were made. A spokeswoman for the Virginia Department of Health Professions said the purpose of such conferences is “to establish which allegations can be proven by clear and convincing evidence.” She declined to comment on Koch’s specific case, citing confidentiality laws.
HCA’s spokesman challenged Virginia’s allegations concerning Koch’s death, saying they wrongly indicated that Collier had worked overnight. HCA said her shift ended the evening before he died, without disputing that she failed to order a blood gas test. Still, Sumerford said, Koch’s care “was appropriate.”
The state put Collier’s license on probation for one year, requiring any future supervisors to submit quarterly reports about the quality of her work. According to the order, she told the state that if she were to pursue future employment as an NP, “she would look for a position where she would be part of a supportive team and have a close working relationship with a physician.” Margaret Hardy, an attorney who represented Collier in her hearings, said her client declined to comment.
As recently as a decade ago, it was unlikely that a nurse practitioner ever would have been put in Collier’s situation.
Tim McManus oversees 57 hospitals in 11 states for HCA. He previously served as Chippenham’s chief executive officer. While in that role, he frequently posted on a blog, since deleted, called “Tim’s Take.” In a post from 2015, viewed in internet archives, he interviewed one of the leaders of Chippenham’s hospitalists—a term that describes practitioners exclusively charged with caring for a facility’s inpatient population. At the time, McManus described the hospitalists as a team of “over 40 physicians” who tackled work that was “incredibly difficult and challenging considering the medical complexity of patients’ illnesses.”
But over the next few years, the team’s makeup changed. The former HCA physician estimated that, by 2020, a fifth of the hospitalists were nurse practitioners—a figure the company didn’t dispute. It was the same team that would employ Collier. For doctors and NPs alike, the physician said, working the night shift was “like being on an island,” where there weren’t enough providers to properly care for patients. Sumerford, the HCA spokesman, declined to answer questions about the hospitalist team’s current staff count.
Hickey, the former Chippenham ER chief, says degradation in the quality of NP education made a bad situation worse. He says he helped train more than 100 NPs and physician assistants as a clinical supervisor but stopped taking on NP students several years ago after noticing that many had been trained entirely online and hadn’t previously worked as a nurse. “They’re hiring people who are unknown entities, and it’s dangerous because you don’t know what you’re getting,” says Hickey, who, as the former president of the Virginia College of Emergency Physicians, advocated for stricter training requirements for NPs who work in the ER.
A rule against staffing night shifts with new graduates, such as the one the Chippenham supervisor said had been implemented, could help prevent putting the least experienced staff in the most challenging scenarios. But no government agency held the hospital to that policy change, apparently because of a bureaucratic lapse. The investigation into Collier was conducted by Virginia’s Department of Health Professions, but Chippenham itself is regulated by the state’s Health Department, a separate agency. Because the second agency wasn’t involved in the Collier inquiry, “we would not reach out to the hospital to verify” policy changes stemming from that investigation, a spokesperson said. Current and former Chippenham employees say the hospital’s ER and ICUs, far from banning new grads on the night shift, rely on them.
Saving on Providers Means Bigger Margins
In a primary care setting, doctors and nurse practitioners bring in similar revenue, but NPs cost significantly less
Source: Kaufman Hall, based on 2022 data
The shift from physicians to nurse practitioners also has affected other high-stakes areas of HCA’s hospitals. Rebecca Mitchell is the former director of clinical operations for Burn and Reconstructive Centers of America, a company that specializes in opening and running burn units in hospitals, two-thirds of them in HCA facilities. She says that by the time she left the company in August 2022, many of the units in HCA facilities had several advanced practice providers for each physician, and that patients experiencing traumatic burns didn’t necessarily see a physician on their first visit, even though the company had a policy mandating they should. In 2023, Mitchell sued both her former employer and HCA, alleging she was wrongfully terminated after raising concerns about the companies’ efforts to obfuscate the credentials of Chippenham’s staff so it could open a burn unit there.
“You’re cutting corners when using a second-level provider,” says Mitchell, who started her career as a nurse in an ICU. “That’s something I fought against.” Mitchell’s lawsuit is ongoing. BRCA didn’t respond to requests for comment.
HCA’s makeover of Mission Health in Asheville, North Carolina, offers a vivid example of how the company’s staffing strategies can affect caregivers, patients and the company’s bottom line.
In 2019, HCA paid about $1.5 billion for Mission Health, a nonprofit system with several facilities and a reputation as one of the Southeast’s premier healthcare centers. HCA executives promised to preserve Mission’s quality while boosting profits by using the corporation’s size to deliver better “purchasing power and back-office efficiencies.” Soon, HCA began drastic staff reductions at the system’s flagship facility, Mission Hospital, and conditions deteriorated rapidly, according to a lawsuit filed by the state attorney general. Wait times in the emergency room swelled, nurse-to-patient ratios in ICUs often fell to half the state minimum, and surgeons reported they frequently lacked sterile medical instruments because of cuts to the cleaning staff, the lawsuit said.
When HCA executives brushed aside complaints from Mission board members and employees, two-thirds of its physicians left, according to a research paper published by Mark Hall, director of the Health Law and Policy Program at Wake Forest University.
Mission’s emergency room was so severely understaffed that it jeopardized patient safety, a federal investigation concluded. One patient who arrived at the ER intubated and critically ill with meningitis died after the overextended medical staff neglected to replace an IV bag that had run dry. Another patient who had fainted and was experiencing chest pains waited more than an hour in the ER before receiving an electrocardiogram. Amid other delays, the investigation found, he died an hour later of a heart attack.
In the wake of that probe, HCA’s plan to correct the deficiencies included an assortment of new training for caregivers and updated triage procedures. Regulators later retested the hospital and found it to be compliant, Sumerford said, adding that Mission now has “approximately the same overall number of providers on its medical staff as in 2019.” He didn’t provide a breakdown of the ratio of physicians to NPs.
The drastic reductions in Mission’s labor costs were a boon to the hospital’s finances. In the four years before the sale, Mission earned an average of $38 million in profit from patient care. In 2022, Mission’s profit reached $96 million, driven primarily by “sharply reduced staffing for patient care under HCA,” according to Hall’s research.
The push wasn’t limited to Mission, according to a Businessweek analysis of labor data for 140 of the company’s hospitals that were reviewed by Hall. In April 2022, HCA’s CEO, Samuel Hazen, told investors on an earnings call that “our productivity is at a very efficient level when it comes to employees per patient.”
Chippenham, Mission Tightened Staffing and Boosted Margins
Change in staffing of care providers and operating margins from 2018 to 2022
Source: National Academy for State Health Policy’s Hospital Cost Tool
Note: Data includes hospitals for which both metrics are available in 2018 and 2022. Outliers representing fewer than 2% of facilities in the sample were excluded. Hospital types shown are as of 2022. HCA hospitals include one government hospital coded to the company in the data and three hospitals running as nonprofit in 2018 that the company later acquired. Care providers are measured as full-time equivalent workers who provide direct patient care. Patients are measured as adjusted discharges.
For now, health-care organizations across the country are looking for ways to deploy NPs and physician assistants while minimizing the risks. “It can either be a cause of success and economic benefit or it can cause a lot of disruption, depending on how you handle it,” Matthew Bates, a managing director at Kaufman Hall, the consulting company, said in a 2023 interview on an industry podcast. Within the next decade, he said, there will be more advanced practice providers than physicians.
In a 2022 article published on the Kaufman Hall website, Bates praised the practices of the industry-leading Emory Critical Care Center at Emory University Hospital in Atlanta. The critical care center employs 200 advanced practice providers and 88 physicians. Not only is that the inverse of the typical staffing, but the supervising physicians don’t roam the wards. They’re sitting in a “centralized system-wide e-command center,” Bates wrote.
Vishal Bakshi, a physician assistant who serves as Emory’s chief advanced practice provider, says the organization has “embraced the idea of having an efficient system of health-care delivery with the APP at the forefront and the physician acting as the manager of the flow,” he says. “There are many ways to do medicine. We are going to do it with APPs as the backbone of the ICU.”
Emory’s model has been successful, but it’s hard to generalize from that experience, says Craig Coopersmith, a physician who serves as director of the critical care center. The physician shortage hit the Southeast before the rest of the country, he says, and his team has been looking for years for ways to better integrate nurse practitioners into their workflows. And Emory is able to rely so heavily on its NPs only because of a rigorous “transition to practice program,” involving as much as six months of night- and day-shift training with multiple mentors, Coopersmith says. It also runs a yearlong fellowship, which was the first of its kind in the country. The program prepares new NPs to perform at a high level, in much the way a physician’s residency might.
Such NP fellowships are still rare, and the federal government doesn’t provide funding to support NP training, as it does for physicians. So NPs’ preparation for intensive care units is still “unbelievably variable,” Coopersmith says. His hospital sometimes takes on NPs from other facilities that give students two to four weeks of training before tasking them with seeing 20 patients on their own. “They’re like, ‘I was dangerous. I didn’t know what I was doing. I didn’t have the backup, and I really need a formalized way of learning,’” he says. At such facilities, “you have no idea, as a patient, the kind of training that person received.”
Those dangers are apparent at hospitals across the country, including some that HCA managed. At Chippenham, NPs weren’t required to have completed fellowship programs. And former members of the hospitalist team say attempts at on-the-job training were insufficient.
Coopersmith’s view is supported by a study, authored by several nurses and published in the Journal of Nursing Regulation, that focused on emergency departments. It found that a small fraction of NPs working in those settings had been certified in emergency care; the rest “are only qualified to care for a subset of patients who arrive in the ED.” The study found that because NPs’ education was so widely varied, they “should not perform independent, unsupervised care” in emergency departments “to protect patient safety.”
But few hospitals are installing such guardrails, leaving a gaping hole for policymakers and the industry to address.
Coopersmith says boosting federal funding for residencies, and expanding it to all providers rather than only physicians, would better prepare America’s emerging health-care workforce for the challenges ahead. “You clearly have people who literally aren’t trained to do what they’re doing,” he says. “There are ways to prevent that.” —With Polly Mosendz, David Kocieniewski, and Demetrios Pogkas