Ballad Merger IV: Has Quality Improved?

Ballad Health signage at Lonesome Pine Hospital. Photo credit: WCB

by Carol J. Bova

As a condition of the merger between Mountain States Health Alliance and Wellmont Health System in 2018, the combined entity, Ballad Health System is required to periodically update Virginia regulators on health metrics for its far Southwest Virginia service territory. Those quality measures and actual performance must be accessible to the public on the Ballad website as well.

The reporting was suspended during the COVID-19 emergency before year-to-year comparisons for Fiscal Year 2020 were available. But Ballad did publish an Annual Report for Fiscal Year 2020 that contained partial data through February 2020.

The bottom line: Quality measures have been a mixed bag. Some measures have improved; a few have declined. As detailed in Parts II and III of this series, Ballad met expectations for cost cutting and restructuring. What isn’t clear from the limited data available is why there is “slippage” in some numbers from one year to the next. Important questions arise.

Are declines attributable to the chronic nursing shortage in Southwestern Virginia and Northeastern Tennessee?

Three Virginia hospitals had to readmit patients within 30 days of discharge at a worse rate than the national average. Did Ballad, incentivized to reduce inpatient days, discharge patients too soon?

Or did “social determinants of health” — such as housing insecurity, lack of transportation, or memory loss affecting the ability to take medications as prescribed – overwhelm Ballad’s best efforts?

The CMS Care Compare website, last updated in October 2020, has reviews for five of Ballad’s Virginia hospitals and one nursing home. (Dickenson Hospital is a critical access hospital with two beds and did not have enough measures reported to calculate a score, and Mountain View Regional is now a nursing home.) The star ratings are 3 for average, 4 for above average and 5 for much above average. CMS combines several individual measures into the categories shown below.

CMS gave Ballad’s nursing home an overall rating of an above-average 4 stars. Health inspections were slightly better than state and national averages. The most recent CMS health inspection, which took place September 6, 2018, resulted in seven citations, all listed as “minimal harm” or “potential for actual harm for few residents.” The national average is 8.1 and the Virginia average is 12.5. There were no complaint inspections between 3/1/20 and 2/28/21. An infection control inspection on 6/22/2020 had no citations.

Mountain View rated 5 stars for staffing, much better than state and national averages. Quality of care rated 3 stars, about average.

System-wide for Ballad’s hospitals, Ballad stated in its Fiscal Year 2020 Annual Report, “The results for thirteen of the seventeen harm measures monitored under the COPA and CA have improved over the 2017 baseline, with reductions in harm ranging from 10% to 60% per measure.” 

Ballad acknowledged in the report that four system-wide measures ­­­–- pressure ulcers, MRSA (Methicillin-resistant Staphylococcus aureus), colon and hysterectomy surgical site infections –- were above the 2017 baseline rates for the partial Fiscal Year 2020. The narrative omitted the fact that five measures were worse than the previous fiscal year 2019.

Ballad’s Virginia hospitals show uneven improvement. (Note: Individual hospitals show sixteen measures and results for FY20 are not available.)

To be fair, some of the measures were minimally above the baseline. Four hospitals had a “hip fractures from a fall after surgery” baseline of .10 and a rate of .11 in subsequent years. One had a .13 rate for 2019. But the system-wide score of .05 shows it is possible to lower the rate.

You can view a breakdown of Ballad quality measures at Ballad Merger Qualty Measures 2017-2020.

The Technical Advisory Panel of the Cooperative Agreement met in December 2020 and discussed meetings held by workgroups and others. Their focus was on additional measures and ways to actively supervise the Cooperative Agreement. Among the items discussed:

  • Ballad will report quarterly quality data at the system, state and facility level.
  • Ballad will propose three performance measures for targeted Quality Improvement.
  • If a measure is retired, Ballad will convene a discussion to select a replacement measure.
  • States may propose additional monitoring metrics to the Technical Advisory Panel (TAP).

After a discussion of what data would be shared publicly, Tom Eckstein of Arundel Metrics, suggested that the smaller facilities should be grouped together to increase the sample size “n” and reduce random variation “noise.” Brenden Rivenbark, Senior Policy Analyst of the Office of the Commissioner, agreed. He also suggested that Ballad “report the data to the States by facility, but that the States would present the data in aggregate.”

Several measures were adopted. This leaves open the question whether Ballad will choose to share CMS reports on quality-safety measures for each hospital in the future. If not, the public will not have detailed quality measures information by hospital. Only a few general points listed on the CMS Hospital Compare site compare national and state averages or system-wide averaged numbers, but CMS provides no good way to track if hospitals are improving or slipping.

The prospect of Ballad making regional improvements in Rural Health, Behavioral Health, Children’s Health and Population Health was a major factor in allowing the merger. Ballad’s plans, and their financing, have been disrupted by the pandemic. What will that mean going forward?

Part V in this series, “Ballad Health Merger and the Pandemic,” will discuss how Ballad handled the COVID-19 epidemic.

Carol J. Bova is a writer living in Mathews County.


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2 responses to “Ballad Merger IV: Has Quality Improved?”

  1. Dick Hall-Sizemore Avatar
    Dick Hall-Sizemore

    Again, great information. This is important, if not juicy, stuff. You make a good point that “social determinants of health” may have “overwhelmed Ballad’s best efforts.” I always made it a point when discussing performance measures with agencies that failure to achieve a measure did not necessarily reflect a failure on the agency’s part. It was a “red flag” that needed investigating. In Ballad’s case, the reasons behind the “below average” scores need to be evaluated more closely to determine if the hospital could have done something better or if there were conditions beyond its control.

    It is early in the merger and the pandemic has disrupted the situation. It seems that there are bright spots in the performance of the reorganized hospitals. One important thing to keep in mind is that the merger has resulted in keeping hospitals open in those communities, while improving their financial health.

    One overall observation: Perhaps the state should consider establishing a similar required agreement, with periodic reports on achievements as part of its approval of other hospitals mergers in the state and in certain COPN approvals.

    Thank you for these in-depth analyses.

  2. My take-away is that if you’re going to create a healthcare monopoly, you need to regulate it. I’m normally opposed to government regulations of business operations, but monopolies are a different situation. The ideal situation would be to open up healthcare in SW Virginia to more competition. But lacking the ability to do that in the current policy environment, regulation and reporting like that which Carol describes does ensure that management doesn’t just build empires (like Sentara appears to be doing).

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