Appalachian hospital ERs slow to a crawl
Monopoly leaves patients with few options in region
In the small Appalachian city of Bristol, City Council member Neal Osborne rushed himself to the hospital Jan. 3.
Osborne, 36, has Type 1 diabetes. His insulin pump 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, he 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 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.
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 U.S. In the six years since lawmakers in both states waived anti-monopoly 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.
Tennessee and Virginia have so far announced no steps to reduce time spent in Ballad ERs. The Tennessee health department, which has a more direct role in regulating Ballad, has each year issued a report saying the agreement that gave Ballad a monopoly “continues to provide a Public Advantage.” Department officials have twice declined to comment on Ballad’s performance.
According to Ballad’s latest annual report, which 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 includes time spent waiting and being treated in the ER and excludes patients who weren’t admitted or left without receiving care.
When compared against the latest corresponding federal data from 2019, which includes more than 4,000 hospitals but predates the pandemic, Ballad ranks among the 100 hospitals with the slowest ERs. More current federal data is not available because the Centers for Medicare & Medicaid Services retired this statistic in 2020.
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 5 hours, 41 minutes — or about five hours faster than Ballad’s latest annual report.
Ballad Health spokesperson Molly Luton said in an email 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 7½ hours in the months since the company’s latest annual report.
“On those issues Ballad Health can directly control, our performance has rebounded from 2022, and is now among the best in the nation,” Luton said.
Luton also noted that Ballad performs better than or close to the national average on several other measurements of ER performance, including having fewer patients who leave without being treated. CMS data shows the national average is about 3%. Ballad reported 1.4% in its latest annual report.
Osborne attributed this statistic to Ballad’s monopoly.
“Just because they aren’t leaving the ER doesn’t mean they are happy where they are,” he said. “It just means they don’t have anywhere else they could be.”
Big monopoly
Ballad Health was formed in 2018 after state officials approved the nation’s biggest hospital merger based on a so-called Certificate of Public Advantage, or COPA, agreement. COPAs have been used in about 10 hospital mergers over the past three decades, but none has involved as many hospitals as Ballad’s.
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.
The Federal Trade Commission warns that hospital monopolies lead to increased prices and decreased quality of care. 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 quality-care metrics spelled out with specific benchmarks.
In its latest annual report, Ballad improved on many quality-of-care metrics over the prior year, but still fell short on 56 of 75 benchmarks.
ER time for admitted patients is one of those. The benchmark was set at 3 hours, 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 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.
Bill Christian, a spokesperson for the Tennessee Department of Health, said Ballad’s rising ER times had been “noted” but did not say if the agency had taken any action.
‘A nightmare’
Ballad has also fallen short — by about $191 million over the past five years — of its obligation to Tennessee to provide charity care — free or discounted care for low-income patients, according to health department documents and Ballad’s latest report. The health department waived this obligation in each of the past four fiscal years. Ballad has said it would ask for another this year.
Ballad CEO Alan Levine defended his company and said that because the Tri-Cities region could not support two competing hospital companies, the COPA merger had likely prevented at least three hospital closures. Levine attributed Ballad’s failure to meet quality benchmarks to the pressure of the pandemic and said charity care shortfalls were partly caused by Medicaid changes.
“Our critics say, ‘No Ballad. We don’t want Ballad.’ Well, then what?” Levine said. “Because the hospitals were on their way to being closed.”
Some residents see Ballad as a savior. John King, who runs a physical therapy clinic in the core of Ballad’s region, said at a public hearing in June that in multiple visits to Ballad ERs, including one for a stroke, he found their care to be quick and compassionate.
“If it weren’t for Ballad Health, I literally would not be here today,” King said.
Ballad’s failures to live up to the terms of the COPA agreement were detailed in a KFF Health News investigation last September, and the company faced a new wave of criticism in the months that followed.
Local leaders in Carter County, Tennessee, in October debated but did not pass a resolution calling for Ballad to be better regulated or broken up. Tennessee Attorney General Jonathan Skrmetti, a Republican, said in an interview with the Tennessee Lookout published in November that Ballad must be constantly monitored in light of community complaints.
In response, Ballad Health said in a statement it welcomed scrutiny from the Tennessee attorney general. Tennessee lawmakers are also considering legislation to forbid future COPA mergers in the state, which Ballad said “risks putting more hospitals at risk for closure.”
The bill was introduced by state Sen. Heidi Campbell (D-Nashville) and state Rep. Gloria Johnson (D-Knoxville), who is running for the U.S. Senate. 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.”