Escalating ER Wait Times Raise Concern Over State-Sanctioned Hospital Monopoly

ER visit wait times for patients seeking care at Ballad Health, a 20-hospital system in the Tri-Cities region of Tennessee and Virginia that benefits from the largest state-sanctioned hospital monopoly in the US, have increased dangerously.  

“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,” reported KFF Health News. 

Ballad Health’s creation via a hospital merger of Mountain States Health Alliance and Wellmont Health System in 2018 was approved despite qualifying as a hospital monopoly because of a Certificate of Public Advantage (COPA) agreement approved by state officials. 

“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,” reported KFF Health News. 

Ballad agreed with officials to meet and report on 75 quality-care metrics with specific benchmarks. In their latest report annual report from July 2022 to June 2023, only 56 out of 75 benchmarks were met, including the benchmark for ER time for admitted patients. 

Ballad reported a median time of almost 11 hours that patients spend in their ERs before being admitted to the hospital. This is a noticeable increase from an originally reported ER wait time of 3 hours and 47 minutes at Ballad’s inception. 

The statistic also excludes patients not admitted or who left without receiving care. This method of measuring time spent in an ER was retired by the Centers for Medicare & Medicaid Services (CMS) in 2020 in favor of other measurements.

According to Ballad Health spokesperson Molly Luton in an email statement, patients are held in the ER to avoid overwhelming staff. ER delays are attributed to a nursing shortage and fewer admissions at nursing homes, causing a backlog of discharged patients. Luton also stated that Ballad’s ER time for admitted patients has dropped to about 7½ hours in the months since the company’s latest annual report.

Luton noted that Ballad also reported an average of 1.4% of patients leaving without treatment compared to a 3% national average found in CMS data. However, this difference could also be attributed to patients lacking alternative options due to the nature of Ballad being a monopoly. 

While the Tennessee Department of Health stated that the agency is aware of Ballad’s rising ER times, no plans for intervention were shared. 

Over the past 5 years, Ballad has also been criticized for falling about $191 million short of its charity care obligation to Tennessee, as outlined in health department documents and Ballad's latest report. The health department has waived this obligation for the past four fiscal years, and Ballad plans to request another waiver this year. 

Ballad CEO Alan Levine defended the company in a two-hour interview last year, attributing the failure to meet quality benchmarks to the pressures of the COVID-19 pandemic and stating that charity care shortfalls were partly due to Medicaid changes beyond Ballad's control.

In 2023, a resolution to regulate or break up Ballad was presented by local leaders in Carter County, Tennessee, but failed to pass. Tennessee politicians have publicly shared concerns over Ballad’s operating practices and leadership. Legislation barring future COPA mergers in the state is also being discussed. 

“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 to KFF Health News on Ballad’s performance,” reported KFF Health News. 

Reference
Kelman B, Liss S. After Appalachian hospitals merged into a monopoly, their ERs slowed to a crawl. KFF Health News. March 25, 2024. Accessed March 26, 2024. www.fiercehealthcare.com/providers/after-appalachian-hospitals-merged-monopoly-their-ers-slowed-crawl