Ballad Health in October stopped performing surgeries at a Norton hospital, but it is unclear if and when patients or state regulators were notified.

“I think that’s something you should tell people if you don’t have an OR,” said Paula Hill-Collins, clinical director of the Health Wagon, which runs free clinics that serve much of Virginia’s coalfields.

Hill-Collins went with a patient in extreme abdominal pain in April to Mountain View Hospital’s emergency room. The patient was admitted but, according to Hill-Collins, did not receive IV fluids or a diagnostic ultrasound. After many hours, she discovered through a series of phone calls that there wasn’t a surgical team at the hospital, and that there hadn’t been one for some time. So she fought to have the patient transferred 50 miles away to Holston Valley Medical Center in Kingsport, Tennessee.

Under a unique regulatory process, Ballad is required to gain Virginia’s permission before reducing any of its service lines. Erik Bodin, director of the Virginia Department of Health division that oversees hospitals, said Ballad has submitted a plan to consolidate services in Wise County but nothing has been approved.

Ballad waited more than a month to respond to a repeated question from The Roanoke Times asking about reductions in services in Virginia. In a June 4 email, it acknowledged that surgeries were stopped in October at Mountain View.

“Given the patient safety and staffing challenges that can accompany low volume services, our surgeons asked us to stop scheduling surgeries at Mountain View while we work together to develop our long-range plans for Wise County,“ the statement said.

A Ballad spokeswoman said someone would answer additional questions, but that has yet to occur.

Hill-Collins said she didn’t know whether she was more upset with Ballad for shutting down surgery or with the state for failing to watch out for the people in Wise County.

“It’s like they don’t realize what’s happened here. I’ll tell you it’s like everything else in Virginia, and this is the absolute truth, when you get to Roanoke, Virginia stops,” she said. “Basically, they don’t care what’s going on here. When we are talking about our people and our patients and being underserved and vulnerable, in the commonwealth of Virginia, we don’t have the same representation that Northern Virginia does. They are the largest population, the richest in the nation, and we’re down here, the poorest. We are not of interest to our legislators.”

FTC attention

When Virginia allowed Mountain States Health Alliance and Wellmont Health Systems to merge, permission came with pages of conditions and with the understanding that the state would provide active and continuing supervision of the newly created Ballad.

Tennessee’s approval was wrapped in similar conditions. Unlike Tennessee, Virginia did not create a local advisory committee responsible for listening to patients, families and staff. Virginia’s technical advisory panel met just once, in April.

Bodin said Ballad files regular reports and his department is in regular communication with the health system and with counterparts in Tennessee’s health department. Ballad’s reports are not filed online, and are not readily accessible to the public.

Bodin said the plan is to develop a more transparent system. The department recently hired an employee who lives in the region to monitor Ballad, and is working with the Southwest Virginia Health Authority to come up with a format for investigating complaints.

The authority is scheduled to meet Wednesday in Abingdon to discuss Ballad and the cooperative agreement.

Del. Terry Kilgore, R-Scott, who chairs the authority, said Tuesday that he was not aware that surgeries had stopped at Mountain View, and said that services should not be curtailed without notification.

“I know Mountain View as one of the hospitals where we knew there would be reductions in some areas, but additions, too, like for substance abuse and psychiatric care, so it was a trade.” Kilgore said they have yet to see additional services.

The authority has not met since December.

Kilgore said they have had trouble getting a quorum, and even “when we have a quorum we have so many folks on the health authority with conflicts. They work for or have a relationship with Ballad.”

He expects that an executive group will be created Wednesday to provide active oversight.

The Federal Trade Commission ordinarily oversees mergers to determine if they will limit access, drive up prices or suppress wages. With a process called COPA, for Certificate of Public Advantage, the states can offer antitrust protection by assuming oversight. The FTC plans to host a workshop June 18 in Washington, D.C., to assess the impact of COPAs on prices, quality, access and innovation. Much of the afternoon is slated to look specifically at Ballad.

Bodin said Virginia officials plan to attend and hope to learn from other states’ experiences.

“This is something that Virginia doesn’t have a lot of experience with, any experience with. And nobody has any experience with it on a scale that Ballad represents, at least not that I am aware of,” he said.

‘Someone’s going to pay’

Ballad operates 21 hospitals in Virginia’s coalfields and around Tennessee’s Tri-Cities. Two of the Virginia hospitals are in Norton and a third is about a dozen miles away in Big Stone Gap.

Despite three hospitals serving Wise County, the Health Wagon has had no shortage of patients who couldn’t access hospital diagnostic and outpatient services. That is changing this year, as Virginia expanded Medicaid to offer insurance for low-income adults, and with the requirement the Ballad expand its charity program.

Teresa Tyson, executive director of the Health Wagon, said they have trouble finding surgeons and hospitals nearby to care for patients with hernias, gallstones and bleeding.

“The patients end up with colon cancer or anal cancer or stomach cancer — whatever it is that’s causing the bleeding — and they die. That’s the reality,” she said. “My plea to the hospital is, you could give us a couple days of OR time and we can either do this now at very minimal cost or they can come back to the ER and present with stage 4 colon cancer, and someone’s going to pay for it. The hospital is going to be out.”

She said the Health Wagon refers patients to a hospital in Pikeville, Kentucky, that sometimes takes them and to a charitable surgical clinic that’s held once a month in Lexington, Kentucky. The University of Virginia in Charlottesville and Carilion Clinic in Roanoke have taken patients, she said, but the distance creates logistical and financial hardships.

Ballad CEO Alan Levine said last summer that he would be shocked to find out his hospitals are turning people away.

Under the COPA, Ballad writes off bills for patients who earn less than 225% of the federal poverty level, which for 2019 is $28,103 for an individual and $57,938 for a family of four.

“I don’t think it’s even remotely reasonable to suggest we aren’t taking care of those communities when other people [health systems] were there and left. If somebody says that, they need to show you evidence of where that has occurred because I would be shocked if somebody could show you a case where there was somebody poor or low income and needed to get in one of our hospitals and could not get in,” he said.

Ballad later reached out to the Health Wagon and offered to have its surgeons see a few patients a month.

Tyson said the first ones got bills, so the program is at a standstill.

‘We should have a say’

In Kingsport, Ballad’s most vocal critics continue to camp outside Holston Valley Medical Center. Their protest began in early May after Tennessee approved Ballad’s request to eliminate Holston Valley’s neonatal intensive care unit and consolidate care of the sickest newborns into Nyswonger Children’s Hospital in Johnson City.

They also seek to disrupt Ballad’s plan to downgrade the level of trauma care at emergency departments at Holston Valley and Bristol, while building up services in Johnson City. They plan to attend the FTC workshop, and are gathering signatures on an online petition in an effort to save both the NICU and higher level of trauma.

Ballad sees this as improving care by concentrating higher-level services in one place, since high volumes generally result in more proficient, safer care and help recruit specialists and subspecialists.

Critics see it as taking away vital services in their communities and worry that people will die when they are forced to travel longer distances in emergencies.

Virginia did not have a say in the nursery levels, as all of that falls within Tennessee. It does, however, expect to review the downgrade of trauma levels, which could affect Virginians who use the closer hospitals in Bristol and Kingsport.

Ballad said it does not have a timetable to share as to when it will institute these changes, nor is it clear how Virginians can comment on the plans.

“While it’s not in Virginia, the plan to reduce trauma at Holston Valley is a big issue that my constituents are complaining about,” Kilgore said. He said Ballad hasn’t done well in communicating its plans.

He said for the merger to be successful Ballad needs to listen to the people in Southwest Virginia.

“We are 46 to 48%, depending on the numbers you look at, of the patient load of the entire Ballad system. We should have a say, absolutely,” he said.

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