NORTON — On a Friday morning in early August, nursing supervisors enter a conference room at Norton Community Hospital, where they’re joined over video by their counterparts at the other two hospitals in Wise County and one in Dickenson County.
For nearly a year, the former competitors have gathered daily to share information on patients and staffing. Today, they have 22 inpatients across three hospitals, which are licensed to care for 10 times as many.
Norton Community is the busiest of the three, with 16 of the patients, a bustling emergency department and booked surgery suites.
At Mountain View Regional Hospital, just two miles away, only three patients have been admitted.
Later that morning, one of the nurses there pulls the chief nursing officer aside to tell him she’s very worried about her job. They have so few patients. They have so few nurses, too, he tells her. She’ll have a job, but it most likely won’t be at Mountain View.
“We really have enough staff to run one hospital in Wise County and we’re running three. That’s the challenge,” said Mitch Kennedy, who recently was promoted from chief nursing officer to chief operating officer of the Wise and Dickenson hospitals.
A week later, Ballad Health announced it will close Mountain View’s medical and critical care units and shut down its emergency room. The patients, Ballad said, can be better cared for safely at Norton Community and Lonesome Pine Hospital, 12 miles away in Big Stone Gap.
This is a start to many changes to come in Wise County, as Ballad seeks to modernize a system that has many empty hospital beds, and yet, still too little access to health care.
Ballad took over ownership of the three hospitals last year following the merger of Wellmont Health System and Mountain States Health Alliance, the two predominant hospital systems in Virginia’s coalfields and Tennessee’s Tri-Cities.
It wasn’t until the veil of competition was lifted that Norton CEO Mark Leonard, who now manages the Wise and Dickenson counties market, could see what Wellmont had done to keep Mountain View afloat.
Very sick patients who had checked into Lonesome Pine’s emergency room were loaded into an ambulance, driven 12 miles over a mountain and admitted to Mountain View’s intensive care unit. One surgical team traveled between the two Wellmont hospitals, leaving moms in labor especially vulnerable should they require an emergency cesarean section, he said.
To be fair, he said, Mountain States also had done all it could to keep its patients out of Wellmont’s grasp, often sending them from Norton Community 70 miles away to Johnson City, Tennessee, when the care they needed might have been only two miles away at Mountain View.
The hospitals focused on staying solvent, while Norton and Wise County residents became among the least healthy people not only in Virginia, but in the nation.
Three hospitals were of little help when there weren’t enough doctors and nurses to keep units open.
Few medical options existed to help people with disabilities and chronic illnesses. Specialty and primary care were limited, and behavioral health care nearly nonexistent. But pain pills were abundant.
During the height of the competition, Norton became an epicenter in the opioid epidemic, with more pills prescribed per capita than elsewhere in the nation, according to a Washington Post analysis of a recently released Drug Enforcement Administration database.
Ballad promised state regulators that if it were granted a monopoly, it would spend money gained through efficiencies to improve the health of the people it serves.
“Maintaining the current state is not an option for us, particularly if we want to do things differently for our neighbors and friends,” Leonard said.
What difference looks like is slowly beginning to emerge.
Last fall, Ballad notified the Virginia Department of Health that it planned to make changes in Norton and Wise County. Since then, Ballad has met with state health officials and supplied more documents. Much of that information has been kept from the public under Ballad’s assertion that it needed to be protected as proprietary information.
Early on, Ballad informed the state that it would no longer perform surgeries at Mountain View, as one team could not safely cover two hospitals 12 miles apart. But Ballad did not make a public announcement, and state officials said they were legally barred from telling the public.
When the change was confirmed and reported in June, Ballad’s leaders said they would be more forthcoming in explaining changes in Wise County. In mid-August, Ballad released a four-page document explaining that it would close Mountain View’s emergency department, intensive care and inpatient units, and its reasons for doing so.
Ballad also said it was working toward adding much-needed behavioral health services, boosting cancer care and working with a visioning committee of medical, educational and community leaders to help determine how best to identify and provide needed services.
A ghost hospital
Mountain View’s four stories are nestled on a serene hillside above Norton. One floor is lively. It was recently renovated and has 44 beds for patients who require care between hospital and home, and for long-term patients for whom this is now their home. Ballad said that won’t change.
The day before, 22 patients had come for emergency care, a handful more than on most days. Otherwise, the building is idle. The lobby is empty, the elevator arrives with haste, the operating rooms are mothballed, and no visitors roam the dimly lit halls.
When Leonard and Kennedy took over management, they began to make changes. Medical and surgical patients were kept in rooms lining two long hallways as if the hospital still cared for dozens of patients, rather than for two or three.
Across a corridor, behind a closed door, ICU nurses cared for another two or three patients.
So they moved the medical and surgical patients into the ICU. It’s helped with staffing, Kennedy said, but there still aren’t enough nurses.
“Last weekend I got a call that said we only have two because one of our nurses called in sick. I sent a supervisor down there with them and said, ‘Don’t take any more patients,’ ” he said. “That’s what creates a diversion.”
The word “diversion” is heard often in Ballad’s world. It happens when patients are turned away from one hospital and sent to another. Critics blame Ballad’s management, but diversions and nursing shortages predate the merger. Ballad places a unit on diversion when it has more patients than staff to care for them.
In the past, if a Wise County hospital was on diversion, patients from both health systems would be sent to Tennessee. But now the former competitors look to each other first.
“In the old world, we were fairly quick to transfer and compete. With a common leadership, we continue to ask, could we have kept this patient? Would it have been safe to keep this patient? Do we have the specialties here?” Leonard said.
Since last fall, that has helped keep 700 patients from leaving the county.
Most transfers to Tennessee now are for a higher level of care, but diversions at one of those larger Ballad hospitals trickle outward, affecting the community hospitals.
A Norton emergency room supervisor reported during the morning huddle one diversion that affected a patient with anaphylactic shock.
“We were trying to go to Holston Valley [Medical Center in Kingsport, Tennessee], but they were on ICU diversion yesterday,” she said. Instead, the patient was flown to Bristol.
But while the patient was still in Norton, the lone physician was tied up with the case, which then increased the door-to-discharge time for other patients.
What about the babies?
Labor and delivery also go on diversion.
“We have one full-time obstetrician at Lonesome Pine and one full-time obstetrician at Norton. As you would expect, they need some time off. They get sick,” Leonard said. Ballad did not provide the cost of hiring outside doctors to fill the gaps.
During the previous 90 days, Leonard said Lonesome Pine had 47 days’ worth of traveling doctors and Norton had 50.
“Even though you go through the credential and vetting process, you really don’t know what you’re getting until they walk through the door,” he said. “The mom-to-be has never seen this person before, so how’s that going over, and by the way, occasionally we can’t get a traveler. So what happens then, we go on OB diversion.”
If a mom in labor shows up, an emergency room doctor will deliver.
“It’s a patient safety issue. It is not a satisfier for the mom and family. As part of that overarching conversation, we need to figure out a different way of doing that,” he said.
During most weeks, both hospitals deliver two or three babies. Sometimes they have as many as six; other times, zero.
Last year, 385 babies were born in Wise County, or 10 fewer than the year before. And the trend line points downward, as does the county’s population.
And that’s a problem.
The American College of Obstetricians and Gynecologists says physicians and nurses need to do 30 deliveries every two years to stay competent, Kennedy said.
With 15 nurses on a unit, each hospital would need to deliver 225 babies a year.
“When a team doesn’t see deliveries orc-sections often enough, you start to have issues with quality,” he said.
He dodged the question of whether obstetrics would be consolidated into one hospital.
“We certainly need to find a resolution to keep the staff competent. That’s for sure,” he said.
Consolidating neonatal services is a sore spot for Ballad. After the merger, it had two specialized neonatal intensive care units in Tennessee but said it did not have enough babies who needed that level of care to keep the required specialists. Tennessee approved the downgrade of the NICU at Holston Valley, and Ballad is making plans to send all to Niswonger Children’s Hospital in Johnson City.
Protesters have camped outside Holston Valley for more than 100 days. They claim the additional distance will prove a hardship for families and might risk the health of the babies by sending them farther away.
Leonard said Norton Community, as a legacy Mountain States hospital, has always sent all its sick babies to Johnson City without any adverse incidents.
Leonard said few people understand the shift in health care away from hospital beds.
He said he’s seen it in his own family. His mother-in-law, who lived in Kingsport until she died last year, was admitted to the hospital several times for urinary tract infections. So when his 87-year-old mother, who lives in Richmond, was not feeling well recently, and her doctor suggested she go to the ER, he assumed she would be admitted. Instead, she was sent home with a prescription after six hours.
“Different state, different doctor, different hospital, but two years ago, a UTI was getting my mother-in-law admitted routinely in Kingsport, but the criteria for admission and being able to meet that criteria continues to get tightened very significantly,” he said. “We talk about the shift from outpatient to inpatient world, that’s the reality from a family perspective on what’s going on.”
Leonard said there is no question they were relying too much on inpatient services.
Medicare, the government’s insurer of elderly people, has pushed for fewer hospital admissions. Even knee replacements, which previously required a stay of several days, are being done on an outpatient basis.
Eight years ago, the inpatient utilization rate, a measurement of admissions per 1,000 people, was 222.7 in Wise County. It has dropped to 126.6 and is expected to decline further. That rate is still above the national average of 98.
The challenge, Leonard said, is to “provide extraordinary inpatient care but also be able to step out into this population health world and work with our physicians and say, maybe what we should be doing, Mrs. Leonard, is working with your physician and having a dialogue so that you didn’t have this downward spiral. Maybe there is some coaching we can give to the doctor, the patient or the family.”
Ballad has said the competition between the two health systems wasted money, strained nursing staff and limited the ability to attract and retain physicians. It says it has in the past year recruited a pulmonologist, a urologist, a hospitalist, a cardiologist, an orthopedist and an internal medicine doctor to Wise County.
Eliminating the need for the surgery team to travel between two hospitals is credited with increasing the overall number of operations at the other hospitals.
Ballad said Mountain View has continued to lose money. But it is hard to independently put a figure to that, as Wellmont in 2013 combined its two Wise County hospitals into one billing and accounting entity.
Before that, Mountain View had lost $13 million between 2009 and 2013, according to reports filed with the Virginia Information System. Lonesome Pine straddled the break-even line, losing some years and gaining in others. Wellmont’s other nearby hospital, in Lee County, was also losing about $1 million a year.
Meanwhile, Mountain States’ Norton Community earned $19.6 million during the same time period.
When Wellmont looked to close a hospital pre-merger, it would have made financial sense to target Mountain View — but that would have allowed Norton Community, owned by its competitor, to gain more of the market.
Instead it closed Lee County’s lone hospital and folded the two Wise County hospitals into one entity.
The following year, Wellmont reported $765,000 in net income for Lonesome Pine and Mountain View, according to American Hospital Directory. That figure had grown to $6.6 million for the reporting period that ended September 2018.
Norton Community grew its net income to $9.3 million last year.
Kennedy said the case for consolidating services goes beyond finances.
“We’ve been so busy making sure everybody does the same things pre-merger — I’m not going to stop doing this because I’m competing with so-and-so — we have not practiced on doing things well,” he said. “So instead of doing it kind of well everywhere, let’s do centers of excellence with whatever we do.”