Ballad says changes will improve safety, not everyone's convinced

Part 3 of a four-part series examining how competing truths over consolidation impact a health system and its community.

JOHNSON CITY, Tenn.—In just over a week, Ballad Health will make some of the most significant changes since its formation.

On Oct. 1, Holston Valley Medical Center in Kingsport, Tenn., will become a Level 3 trauma center—downgraded from Level 1 and requiring fewer specialists. Once it’s all said and done, Johnson City Medical Center a half-hour south will emerge as the region’s only Level 1 trauma center and neonatal intensive care unit.

Ballad has said the two hospitals, owned by its predecessors Wellmont Health System and Mountain States Health Alliance, built up duplicative services that would be safer if delivered from fewer high-volume centers.

“Every study on trauma says if you dilute volume, you have poor outcomes, particularly for head injuries,” said Ballad’s CEO, Alan Levine.

But there is concern over whether Johnson City can handle the load.

“Neither one of those hospitals can swallow the overall care of both of those hospitals,” said Dr. Oscar Guillamondegui, a surgery professor at Vanderbilt Trauma and Surgical Care Clinic and chair of Tennessee’s committee on trauma, in reference to the planned trauma changes.

Formed in February 2018 through a controversial state maneuver that allowed it to avoid a federal lawsuit, Ballad is aggressively consolidating services across its 21-county region in northeast Tennessee and southwest Virginia. Many residents say they're concerned the changes are leading to unsafe conditions and higher bills, claims Ballad refutes.

In interviews discussing the trauma changes, several Ballad executives repeated Levine's belief that it’s safer to consolidate high-level services into one tertiary center, and added that very few cases would transfer from Kingsport to Johnson City.

“The majority of our trauma will still be cared for here,” said Lindy White, CEO of Ballad’s Kingsport market, which includes Holston Valley. “That’s the message we’ve done our best to integrate in the community. But not everyone has been able to grab on to that concept.”

Despite Ballad’s assurance that the changes should lead to safer care, some local residents and medical providers are deeply concerned they’ll have the opposite effect. They routinely cite the so-called “golden hour” rule in trauma medicine, which states that a patient’s odds of survival are largely determined by the care provided within the first hour. Data show Holston Valley’s coverage area extends far into southwest Virginia, where curving roads wind up and down rolling hills.

“I can think of patients we’ve treated who literally would have died if they had to go down the road to Johnson City,” said Dr. John Keeley Jr., a trauma surgeon at Holston Valley Medical Center. He said he resigned because of the changes but has agreed to work at the hospital through the end of September.

Julie Bennett, a Ballad board member, said she thinks people’s concerns aren’t so much about quality of care, but how much longer it will take to drive back and forth from Johnson City.

“It's a convenience issue; it's not a care issue,” she said.

The capacity of Johnson City Medical Center is being tested at a time when quality there is mixed. 

The hospital's performance declined on eight out of 17 quality target measures between July 2018 and February 2019 compared with a 2017 baseline, according to a Ballad quality report. The rates of catheter-associated urinary tract infections and MRSA increased during that time, as did the rate of colon surgical site infections.

Meanwhile, Holston Valley in Kingsport performed better on all but three of the 17 measures in that time. The rate of central venous catheter-related blood stream infections dropped to zero and the catheter-associated urinary tract infection rate dropped as well.

Systemwide, Ballad, which commissioned the report through a third-party vendor, performed better on 12 of 17 quality target measures compared with the 2017 baseline, with performance declining for catheter-associated UTIs and MRSA. The rate of hysterectomy surgical site infections dropped to zero and the system’s post-operative sepsis rate declined significantly, as did its postoperative respiratory failure rate.

The Joint Commission performed an unannounced “for-cause” inspection of Holston Valley and the cancer center at Ballad’s Indian Path Community Hospital in Kingsport this month to assess compliance with Medicare conditions. The accreditor found the hospital to be in substantial compliance, according to a letter shared by Ballad.

But not everyone trusts Ballad’s numbers.

Dr. Robert Berry, an internal medicine physician who runs a direct primary-care practice in Greeneville, Tenn., challenged Ballad’s assertion that it has dropped its infection rate for abdominal hysterectomy patients to zero. He said one of his patients had a hysterectomy at a Ballad facility last fall with many complications, including sepsis, and nearly died.

“I only mention this with her permission to show that Ballad’s self-reported information might not always be trustworthy and we should acknowledge that going forward,” Berry said at a recent public forum.

"We have no evidence to support Dr. Berry’s assertion, and he has not shared any information with us," said Levine, urging Berry to share the patient information. "In each case where there is an infection, we investigate those for the purpose of reducing harm."

Some community members are concerned about Ballad moving certain services to hospital campuses.

Ballad in March moved its Kingsport cancer services to the campus of one of its hospitals in that city.

Kingsport resident Lucian Lawson, 72, believes Ballad's motivation was to "jack up the prices."

New patients will be charged the facility fees all hospitals are currently allowed to charge to offset the cost of operating those facilities.

Levine vehemently denies Lawson's assertion.

He says the change eased access and restored that clinic’s eligibility for the federal government’s 340B drug-discount program. Patients in Kingsport and Lebanon, Va., who receive certain sleep services will also be charged facility fees as the result of another move.

In response to criticism about the facility fees, Levine touts the fact that Ballad is spending $15 million to reopen a shuttered hospital in Lee County, Va., a move that was not required under the agreement that allowed the merger to occur.

Ballad also recently opened a replacement hospital in Unicoi County. Unicoi County Hospital Administrator Eric Carroll said replacing the hospital was part of the deal when Mountain States acquired the facility in 2013.

On the other hand, Ballad has closed urgent-care clinics in Johnson City, Kingsport and Greeneville, Tenn., as well as one in Abingdon, Va. Levine said Ballad is consolidating urgent-care services into other clinics in those areas.

Following Ballad’s merger, a group of owners, including Ballad, closed two ambulatory surgery centers in Kingsport and Bristol. The details are in dispute, but Dr. Scott Fowler, CEO of the Holston Medical Group, an independent physician practice that formerly operated in those centers and competes with Ballad for outpatient surgeries, claims Ballad is trying to shut down competition and drive more services into its hospitals. Levine claims Ballad could not have closed them on its own.

However, in making some of those changes, Ballad is bucking a national trend.

Across the country, health systems are increasingly shifting services away from hospital campuses into communities, where it’s cheaper and easier for patients to access. The American Hospital Association found the ratio of hospitals’ net outpatient care to inpatient care was 95% in 2017, up from 83% in 2013. Not-for-profit giant Ascension announced in 2018 it would transition from being a hospital-oriented system to one focused on outpatient care and telemedicine.

Levine said Ballad is working to expand its outpatient points of care, and this year reduced low-acuity admissions by 5,000. He said the health system is investing in new urgent-care sites and behavioral health through telemedicine. He added that 60% of Ballad’s revenue is now outpatient.

In some cases, patients in Ballad's coverage area will have to travel longer distances for trauma care after Oct. 1.

The Southwest Virginia EMS Council estimates roughly 160 patients within its 13-county region will require Level 1 trauma care each year, based on historical data that showed about 1,000 total injury calls per year. Greg Woods, the group's president said it's a relatively small, but not insignificant number.

However, “long travel is not new for southwest Virginia, just by nature of our geography and structure,” he said.

Ballad plans to downgrade its third trauma center, Bristol Regional Medical Center, from a Level 2 to a Level 3 in 2021, according to a Ballad fact sheet from July. 

Ballad was formed through an agreement called a certificate of public advantage approved by the states of Tennessee and Virginia; the agreement governs things like prices and physician hiring. It also precludes Ballad from making changes to certain services without first notifying state regulators.

Dr. Lisa Piercey, Tennessee’s health commissioner, wrote in a May letter to Levine that her department should have received a written request to downgrade the Bristol trauma center, which was not pre-approved in Ballad’s COPA. She called it a “disappointing oversight.” Levine said in an interview he notified the health department well in advance, just not in a “more specific letter.”

Levine appears to be correct in his rationale for the changes.

Research has shown that consolidating trauma services produces better outcomes. A 2017 review of 66 studies on regionalized trauma services concluded there is indeed a correlation between regionalized networks of trauma care and lower trauma deaths. The review, published in the journal Public Health, recommended further study. A 2001 JAMA study found a strong association between trauma volume and outcomes, with significant improvement in mortality and length of stay when volume exceeded 650 cases per year, which both of Ballad’s existing Level 1 trauma centers exceed.

Still, whenever a hospital pulls services, medical professionals who are affected are almost sure to get upset, and Ballad is no exception. Levine conceded in a July letter to Tennessee’s health commissioner that two of Holston Valley’s four trauma surgeons resigned. Although he did not say why they had left, he assured state regulators that there was "appropriate coverage" through September 2019.

Vanderbilt’s Guillamondegui said it’s hard to change the culture of an area that’s been doing things the same way for decades.

But he pushes back on Ballad's claim that Johnson City Medical Center has enough specialists to handle an increased number of trauma patients, especially if it starts to see more transfers.

“I can tell you there are not enough orthopedists at one center or the other to do the work of both centers,” Guillamondegui said, “That’s where you’re going to run into trouble.”

White, the Kingsport market CEO, countered that Holston Valley has a “robust” orthopedic team, with at least 15 physicians who rotate on call. One orthopedic surgeon will be on call at all times, which is the same way the hospital operated as a Level 1. Levine said, overall, Johnson City had a more stable supply of adult and pediatric specialists than Holston Valley.

Although Ballad’s executives assure the change is not primarily about saving money, a separate Bishop & Associates report dated September 2018 shows Ballad will save an estimated $2.8 million annually by downgrading Holston Valley to a Level 3. Ballad also expects to save $1 million a year from the hospital's NICU closure, Levine wrote in a January letter to Tennessee’s then-health commissioner.

Modern Healthcare Metrics data show that hospital lost $14.7 million in 2018.

Some community members, especially those in Kingsport, have maintained that Holston Valley should have retained Level 1 trauma status and its NICU because of its more centralized location within Ballad's coverage area. State data show Sullivan County, where Kingsport is located, sees the state’s highest rate of babies born with neonatal abstinence syndrome, problems caused when babies withdraw from drug exposure—most often opioids—in the womb.

Levine said the NICU downgrade is necessary because of a Tennessee perinatal plan that calls for regionalization of high-acuity prenatal services. The plan says Level 3 NICUs like Holston Valley must have pediatric medical and surgical specialists, but he said it has no pediatric surgeons and few, if any, pediatric medical specialists. He also said the Johnson City Medical Center receives federal funding as a safety-net hospital, a status that requires it to have a Level 1 trauma center and regional perinatal center.

“The idea of stripping Level 1 trauma or NICU from here and bringing it to Holston Valley, we would've been left without an essential access safety-net hospital (for) the whole region,” he said. “You wouldn't move your NICU away from your children's hospital.”

Lisa Carter, CEO of Niswonger Children’s Hospital, which is attached to the Johnson City Medical Center, said keeping the NICU in the Johnson City hospital was a no-brainer.

“It was the easiest decision we’ve made,” she said.

Ballad shared data with Tennessee’s former health commissioner that shows Holston Valley’s NICU admitted 272 patients in fiscal 2018. Of those, 83 were treated for neonatal abstinence syndrome.

Once that NICU closes, Ballad told the former commissioner that it estimates only 100 additional babies would require transport to Niswonger.

Levine explained that estimate is because babies treated for neonatal abstinence syndrome
should not be treated in the NICU. They should instead be cared for in special units that are quiet and dimly lit. There is already one such unit at Niswonger, and he said Ballad plans to add another at Holston Valley and in its Abingdon, Va., hospital.

The state data show neonatal abstinence syndrome births in Tennessee are concentrated in Ballad's northeast service quadrant that includes Holston Valley and Abingdon.

In southwest Virginia, hospital administrators say they’re adjusting to a new reality of rural healthcare: a rapidly declining inpatient census.

At three of Ballad’s rural Virginia hospitals—Norton Community Hospital and Mountain View Hospital, about two miles from one another in Norton, and Lonesome Pine Hospital about 20 minutes away in Big Stone Gap—inpatient use has gone from about 222 per 1,000 in 2010 to about 126 per 1,000 today, said Mark Leonard, CEO of Ballad’s operations in Virginia’s Wise and Dickenson counties.

“The way we’re structured is not sustainable with the low volume of patients that are at Mountain View or Lonesome Pine,” he said. So "is there a way to reconfigure and provide services differently?”

The answer to that question is a work in progress. Ballad is awaiting approval from Virginia regulators to substantially consolidate services across those three hospitals. If approved, it will close Mountain View’s emergency room and permanently discontinue surgeries and intensive-care services there, among other changes. Ballad also eventually plans to stop delivering babies at one of its hospitals in Norton, population about 4,000. That change will require state approval.

Leonard said his eventual vision for Mountain View, one that’s at least a few years out, is to turn it into an inpatient or outpatient behavioral health facility, possibly to treat substance abuse. Ballad has already announced plans to turn one of its hospitals in Greeneville, Tenn., into a residential substance abuse treatment facility for women. Leonard said he’d also like to expand the hospital's post-acute services.

Ballad spokeswoman Teresa Hicks said Leonard’s open communication about his vision for the hospital is one example of Ballad’s effort to be more transparent about changes before they’re made.

“That’s a different way of communicating and operating,” she said. “I think the community and our team members appreciate that, but it can be uncomfortable at times.”

Kathy Christian is part of the group of protesters camping outside Holston Valley in Kingsport for more than 130 days in an effort to get Ballad to reconsider its trauma and NICU changes. She’s motivated not only by her own family’s experience—her grandson had a poor outcome receiving care at a Ballad hospital—but by accounts she’s heard from many others.

“It’s overwhelming the people that stopped here to tell their stories,” the 62-year-old Church Hill, Tenn., resident said. “For me, it started with my grandson and what happened to him. But also just the passion that we have for our community and for our families. It’s really scary.”

The final story in our four-part series looks at the staff reductions Ballad's made that residents say are affecting quality of care.