During the Great Recession, when many hospitals across the country were nearly brought to their knees by growing numbers of uninsured patients, one hospital system not only survived - it thrived.
In fact, profits at the health care industry giant , which controls 163 hospitals from New Hampshire to California, have soared, far outpacing those of most of its competitors.
The big winners have been three firms - including Bain Capital, co-founded by Mitt Romney, the Republican presidential candidate - that bought HCA in late 2006.
HCA's robust profit growth has raised the value of the firms' holdings to nearly three and a half times their initial investment in the $33 billion deal. The financial performance has been so impressive that HCA has become a model for the industry. Its success inspired 35 buyouts of hospitals or chains of facilities in the last two and a half years by private equity firms eager to repeat that windfall.
HCA's emergence as a powerful leader in the hospital industry is all the more remarkable because only a decade ago the company was badly shaken by a wide-ranging fraud investigation that it eventually settled for more than $1.7 billion.
Among the secrets to HCA's success: It figured out how to get more revenue from private insurance companies, patients and Medicare by billing much more aggressively for its services than ever before; it found ways to reduce emergency room overcrowding and expenses; and it experimented with ways to reduce the cost of medical staff, a move that sometimes led to conflicts with doctors and nurses over concerns about patient care.
In late 2008, for instance, HCA changed the billing codes it assigned to sick and injured patients who came into the emergency rooms. Almost overnight, the numbers of patients who HCA said needed more care, which would be paid for at significantly higher levels by Medicare, surged.
HCA, which had lagged the industry for those high-paying categories, jumped ahead of its competitors and was reimbursed accordingly. The change, which HCA's executives said better reflected the service being provided, increased operating earnings by nearly $100 million in the first quarter of 2009.
To some, HCA successfully pushed the envelope in its interpretation of existing Medicare rules. “If HCA can do it, why can't we?†asked a hospital consulting firm, the Advisory Board Company, in a presentation to its clients.
In one instance, HCA executives said a private insurer, which it declined to name, questioned the new billing system, forcing it to return some of the money it had collected.
The hospital giant also adopted a policy meant to address an issue that bedevils hospitals nationwide - reducing costs and overcrowding in its emergency rooms. For years, the hospital emergency room has been used by the uninsured as a de facto doctor's office - a place for even the most minor of ailments. But emergency care is expensive and has become increasingly burdensome to hospitals in the last decade because of the rising number of uninsured patients.
HCA decided not to treat patients who came in with nonurgent conditions, like a cold or or even a sprained wrist, unless those patients paid in advance. In a recent statement, HCA said that of the six million patients treated in its emergency rooms last year, 80,000, or about 1.3 percent, “ chose to seek alternative care options.â€
“Many E.R.'s in America, particularly in densely populated urban areas where most HCA-affiliated facilities are located, have adopted a variety of systems to determine whether a patient in fact needs emergency care,†the statement said. “About half our hospitals have done so. Typically, our affiliated hospitals have two caregivers - usually a triage nurse and a physician - make that determination. It should be noted that other non-HCA affiliated hospitals are using similar processes to address E.R. issues.â€
As HCA's profits and influence grew, strains arose with doctors and nurses over whether the chain's pursuit of profit may have, at times, come at the expense of patient care.
HCA had put in place a flexible staffing system that allowed it to estimate the number of patients it would have each day in its hospitals and alter the number of nurses it needed accordingly.
Several nurses interviewed said they were concerned that the system sometimes had led to inadequate staffing in important areas like critical care. In one measure of adequate staffing - the prevalence of bedsores in patients bedridden for long periods of time - HCA clearly struggled. Some of its hospitals fended off lawsuits over the problem in recent years, and were admonished by regulators over staffing issues more than once.
Many doctors interviewed at various HCA facilities said they had felt increased pressure to focus on profits under the private equity ownership. “Their profits are going through the roof, but, unfortunately, it's occurring at the expense of patients,†said Dr. Abraham Awwad, a kidney specialist in St. Petersburg, Fla., whose complaints over the safety of the programs at two HCA-owned hospitals prompted state investigations.
This article has been revised to reflect the following correction:
Correction: August 14, 2012
An earlier version of this article imprecisely referred to the state of Mitt Romney's candidacy. He is the presumptive Republican presidential nominee; he is not yet the nominee.
