Monopoly benefits Tenn., Va. hospitals
But ER wait times have tripled in Ballad’s system
In the small Appalachian city of Bristol, Virginia, City Council member Neal Osborne left a meeting on the morning of Jan. 3 and rushed himself to the hospital. Osborne, 36, has Type 1 diabetes. His insulin pump had malfunctioned, and without a steady supply of this essential hormone, Osborne’s blood sugar skyrocketed and his body was shutting down.
Osborne went to the nearest hospital, Bristol Regional Medical Center. He said he settled into a wheelchair in the emergency room waiting area, where over the next few hours he drifted in and out of consciousness and retched up vomit, then bile, then blood. After 12 hours in the waiting room, Osborne said, he was moved to an ER bed, where he stayed until he was sent to the intensive care unit the next day. In total, the council member was in the ER for about 30 hours, he said.
Osborne said his ordeal echoes stories he’s heard from constituents for years. In his next crisis, Osborne said, he plans to leave Bristol for an ER about two hours away.
“I want to go to Knoxville or I want to go to Roanoke, because I do not want to further risk my life and die at a Ballad hospital,” he said. “The wait times just to get in and see a doctor in the ER have grown exponentially.”
Ballad Health, a 20-hospital system in the Tri-Cities region of Tennessee and Virginia, benefits from the largest state-sanctioned hospital monopoly in the United States. In the six years since lawmakers in both states waived antimonopoly laws and Ballad was formed, ER visits for patients sick enough to be hospitalized grew more than three times as long and now far exceed the criteria set by state officials, according to Ballad reports released by the Tennessee Department of Health.
According to Ballad’s latest annual report, which was released this month and spans from July 2022 to June 2023, the median time that patients spend in Ballad ERs before being admitted to the hospital is nearly 11 hours. This statistic includes both time spent waiting and time being treated in the ER and excludes patients who weren’t admitted or left the ER without receiving care.
The federal government once tracked ER speed the same way. When compared against the latest corresponding federal data from 2019, which includes more than 4,000 hospitals but predates the COVID-19 pandemic, Ballad ranks among the 100 hospitals with the slowest ERs.
Newer data tells a similar story. The Joint Commission, a nonprofit that accredits health care organizations, collected this same measurement for 2022 from about 250 hospitals that volunteered the data, finding a median ER speed of five hours and 41 minutes.
Ballad Health spokesperson Molly
Luton said in an email statement that, by holding patients in the ER, where they are observed while waiting for a bed, Ballad avoids “overwhelming” its staff. Luton said ER delays are also caused by two nationwide crises: a nursing shortage and fewer admissions at nursing homes and similar facilities, which can create a backlog of patients awaiting discharge from the hospital.
Luton added that Ballad’s ER time for admitted patients has dropped to about 71⁄2 hours in the months since the company’s latest annual report.
Ballad Health was formed in 2018 after state officials approved the nation’s biggest hospital merger based on a socalled Certificate of Public Advantage, or COPA, agreement.
State lawmakers in Tennessee and Virginia waived federal anti-monopoly laws so rival hospital systems – Mountain States Health Alliance and Wellmont Health System – could merge into a single company with no competition. Ballad is now the only option for hospital care for most of about 1.1 million residents in a 29-county region at the nexus of Tennessee, Virginia, Kentucky, and North Carolina.
To offset the perils of Ballad’s monopoly, officials required the new company to commit to a long list of special conditions, including dozens of qualitycare metrics spelled out with specific benchmarks.
In its latest annual report, Ballad improved on many quality-of-care metrics over the prior year, including several that the company prioritized, but still fell short on 56 of 75 benchmarks.
ER time for admitted patients is one of those. The benchmark was set at three hours and 47 minutes in the original COPA agreement. Ballad met or nearly met this goal for three years, according to its annual reports. Then the ERs slowed.
In 2022, Ballad reported a median ER time for admitted patients of about six hours.
In 2023, it reported the same statistic at seven hours and 40 minutes.
In the latest report, ER time for admitted patients had reached 10 hours and 45 minutes.
CMS, which grades thousands of hospitals nationwide, warns on its website that timely ER care is “essential for good patient outcomes,” and that more time spent in the ER has been linked to higher complication rates and delays in patients getting pain medication and antibiotics.
Local leaders are now debating on whether Ballad should be better regulated or broken up. Tennessee lawmakers are also considering legislation to forbid future COPA mergers in the state. Johnson said the bill would end Ballad’s protection from antitrust laws.
“It’s just been a nightmare for community members out there,” Johnson said. “And they have no other option.”
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