Southwest VA’s Health Crisis Began Before the Pandemic

This map shows the region served by the Southwest Virginia Health Authority. (From the Virginia Letter Authorizing a Cooperative Agreement)

by Carol J. Bova

The looming COVID-19 hospital crisis in Southwest Virginia was set in motion long before the pandemic.

To begin with, the region’s health indicators and outcomes generally are much worse than the state average. Two indicators particularly impact the COVID-19 epidemic: Every county in the Southwest Virginia Health Authority service area has a higher percentage of obese adults than the state as a whole. Similarly, the diabetes rate in the counties of Lee, Scott, and Wise, and the City of Norton is 19.1%.

Against this comorbidity backdrop, a nursing shortage at the region’s largest health provider, Ballad Health, is making it impossible to staff enough hospital beds to serve Southwest Virginia’s COVID-19 patients.

On December 2, 2020, reported from information supplied by Ballad Health: “Due largely to this nursing shortage, Ballad Health is nearly at capacity. The system is at 93% patient occupancy, including 92% of all ICU beds. Furthermore, more than 200 staff members are currently isolated or in quarantine due to confirmed or potential infection.”

Ballad Health CEO Alan Levine described the dilemma: “Ballad Health has the supplies it needs to treat coronavirus patients. It has the bed space and  ventilators. But capacity is determined by the staff availability. Given the nursing shortage the system is facing, the key at this point is to keep as many people as possible out of the hospital.”

Ballad has already halted elective surgeries that require an overnight stay in order to shift staff, but it still needs to hire 350 more nurses.

To put this situation into context requires a look at the merger creating
Ballad Health.

In June, 2019, the Tennessean, part of the USA Today Network, published ”Medical monopoly: An unusual hospital merger in rural Appalachia leaves residents with few options.” The article discussed what the publication called “an unusual and controversial merger between two rival hospital systems headquartered in northeast Tennessee.”

On October 30th, 2017, Virginia’s then-State Health Commissioner, Marissa J. Levine, approved an application in a Letter Authorizing a Cooperative Agreement between Mountain States Health Alliance and Wellmont Health System to merge under the name of Ballad Health. (According to the 151-page document, the Southwest Virginia Health Authority had recommended approval in November, 2016.)

The merger creating Ballad Health affected 29 counties in northeast Tennessee and nearby parts of Virginia, North Carolina and Kentucky, a region the size of New Jersey.

In an August 2019 report of its first year, Ballad pointed to a national shortage of nurses as a concern, noting that it would make a $10 million annual investment to boost direct-patient care nursing wages, affecting nearly one-third of Ballad Health’s workforce.

Ballad said it used its entire operating income of $9.9 million in fiscal 2018 to do this. Only later in the report did it mention that for the year ending June 30, 2019, operating income had risen to $36.5 million. The health system attributed the improved finances to expense and supply cost management and reduced reliance on temporary contract labor. In a different context, it also noted that it had reduced “the use of temporary traveler nurses by 50% over the last year.” It did not say how many jobs were eliminated by the 50% reduction.

The Southwest Virginia Health Authority (SWVA) created a Task Force in 2019 to oversee Ballad for Virginia and hired three staff members to help it navigate the application for a cooperative agreement. One of the three, Dennis Barry, a retired healthcare attorney, serves as the merger monitor.

The terms of the merger set goals of spending $75 million over ten years for population health improvement and investments of $70 million over ten years to address differences in salary and benefit structures among employees in the new health system.

Unlike in Tennessee, the Virginia Department of Health says “it closely monitors Ballad, but reports are not available to the public.” ( went on to say in a January 6, 2020 article:

Two years since the creation of Ballad, the state has yet to release quality, access and financial reports with the public. And people living in far Southwest Virginia have yet to be given a public forum to tell regulators whether Ballad is living up to a list of conditions to ensure access to health care, to improve its quality and to do so without hiking prices.

In his first report as Merger Monitor to the SWVA Board on January 3, 2020, Barry said that, while Ballad is taking steps to recruit and retain more nurses, the nursing and allied health shortage will not be alleviated in the short-term and is likely to continue to affect Ballad and its patients for at least the near-to mid-term future. One item on the Authority’s Merger Monitor’s agenda is to research more fully what Ballad is doing to address the problems caused by the nursing shortage.

On December 2, 2020, quoted Ballad Chief Physician Executive Clay Runnels as saying that Ballad Health was hoping to increase capacity to 460 beds specifically for COVID patients. However, the publication added, “given the rate at which the virus is spreading in the region, Ballad is heading for a peak of more than 500 people hospitalized by the end of December. Currently, there are less than 15 ICU beds available across the entire system.”

The merger application indicates a reduction from 526 licensed hospital beds in Virginia to 341. Ballad Health hospital websites do not give total number of beds. In the chart below, 2013 and 2015 are compiled from the Ballad Health Merger Application /VHI; 2020 numbers come from Virginia Health Information (VHI).

According to minutes posted online, when the Southwest Virginia Health Authority Task Force met on November 19, 2020, Barry advised that Ballad had submitted the required annual report to compliance monitors at the end of October, 2019. The report had two portions — one, 270 pages long, contained nonconfidential information; the other, more than 300 pages long, contained information that Ballad had identified as being confidential, proprietary, or containing commercial/business information that it couldn’t disclose. Copies were not included in the meeting packet.

The November, 2020 Task Force meeting, the agenda called for Barry to address several issues, among them:

• Terms of the Cooperative Agreement and Tennessee requirements suspended during COVID-emergency.
• The effects of COVID-19 on Ballad, presented by Ballad with slides
submitted in advance.
• Ballad’s financial results for FY 2020, and budget for FY 2021
(confidential if Ballad wants to treat it that way, presented by Ballad with slides submitted in advance.
• Determination of spending shortfall.
• Problems with the Cooperative Agreement and the Tennessee Terms of Certification are becoming apparent.

The issue of Ballad’s nursing shortage was conspicuously absent from the list, as were details of which merger requirements were suspended.

The Southwest Virginia Health Authority (SWVA) Board will meet by Zoom on December 9th, but there is no information packet online yet to see further details on the November Task Force meeting.

Update and Correction: On June 24, 2020, the Virginia Department of Health did post online the “Virginia State Health Commissioner’s Annual Decision Regarding the Ballad Health Cooperative Agreement for the period of June 1, 2018- June 30, 2019. This document was not included in the Southwest Virginia Health Authority Task Force November 19, 2020 meeting packet or SVHA website.

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30 responses to “Southwest VA’s Health Crisis Began Before the Pandemic”

  1. Reed Fawell 3rd Avatar
    Reed Fawell 3rd

    Yet, at the same time, I recall a very recent report that this region’s new casino was the most profitable in the state. Am I wrong? Or does rampant gambling feed off high levels of ill health and economic distress among the population? And does state sanctioned casinos keep this vicious circle of despair going, along with low levels of heath care.

    1. idiocracy Avatar

      It’d be interesting to see a map showing where the most lottery tickets are sold in Virginia…

      1. Nancy_Naive Avatar

        It would probably correlate very well with Prosac sales. Or should.

        1. idiocracy Avatar

          Prozac? Why would any Real Virginian need Prozac? They only need to comfort themselves with these words:

          “To be a Virginian, either by birth, adoption, or even on one’s Mother’s side, is an introduction to any state in the union, passport to any foreign country, and a benediction from the Almighty God”

          One can probably even use a mug printed with this to catch the water leaking from the roof they can’t afford to fix!

          1. Nancy_Naive Avatar

            Because it’s safe to take with oxycodone?

        2. idiocracy Avatar

          Maybe not. Ever heard of serotonin syndrome?

          1. Nancy_Naive Avatar

            Makes me sleepy just thinking about it.

            Actually, no. Is it a prosac thing?

        3. idiocracy Avatar

          It can be caused by mixing Prozac with other drugs, one of which is oxycodone.

          1. Nancy_Naive Avatar

            I took one — count it — oxycodone. I will never take another. Instant drowsy with a scary drop in respiration.

    2. Reed Fawell 3rd Avatar
      Reed Fawell 3rd

      Sounds like casino business is booming in this land of need and despair. I wonder if the Speaker’s fund coffers are overflowing.

      Here’s how many casinos are designed and work hard to impoverish vulnerable people in whole regions. Like Va.’s health care system, they’re often monopolies too.

      Reed Fawell 3rd | January 12, 2019 at 9:59 am | Reply

      For more details, here is a very much shortened version of an article published in The Guardian Newspaper titled: Slot Machines: a lose lose situation, by Tom Vanderbilt June 8, 2013

      “Once seen as a harmless diversion, hi-tech slot machines now bring in more money than casinos – and their players become addicted three times faster than other gamblers. We investigate how the industry keeps us hooke. The first thing you notice on entering the vast hall of the casino is the sound: …It all percolates and pulsates in a gently propulsive fashion, as if to convey a sense of progress even as it relaxes…

      In her book Addiction By Design: Machine Gambling In Las Vegas, Natasha Dow Schüll, an anthropologist at the Massachusetts Institute of Technology, writes that in the late 1990s the “prescient audio director” at Silicon Gaming decided that every one of the sounds made by its slot machines – a number that now exceeds some 400 discrete noises – would be issued in what she terms “the universally pleasant tone of C’… The sonic strategy is at one with an overall ethos that Schüll terms “smoothing the ride”, a holistic mantra running through the casino experience …”all of it is in the service of maintaining the flow.”

      … “Gambling, as I see it, is an irrational behaviour that is impulsive.” …She arrived during one of the city’s periodic building booms, including a particular surge in what are known as “locals’ casinos” – not the flashy, themed spectacles of the Strip, but more low-key, less mazy centres for “convenience gambling”, as the industry calls it, where residents comprise up to 90% of the haul and machine games such as video poker dominate. She didn’t need academic research to gauge this latter trend. “I was staying with my boyfriend’s grandmother, who lived right across the street from the Gold Coast, a locals’ casino. We noticed that she got up every night at 2am, and she would be gone until about 10am. We figured out that she was going and playing video at the Gold Coast.”

      While Schüll’s research began with casino architecture, it is the rise of these machine games – and their carefully calibrated machine-user interfaces that, she says, enable, if not exactly seek, addictive behaviour – that became her ultimate focus. “I’m not playing to win,” one Vegas resident told her. She was playing, Schüll says, “to keep playing – to stay in that machine zone where nothing else matters”.

      I have intercepted Schüll, on her way to teach a doctoral seminar at Columbia University, to walk me through Resorts World casino in Queens, New York. … I enter the casino driveway, ascend the multistorey car park and a few short steps later am on the floor. This is where “flow” begins. In the words of Bill Friedman, a legendary Las Vegas casino designer interviewed by Schüll, “Driving from the street into the property should be effortless.” … and Like most casinos in Vegas, it is large, its geography blurred (paramedics told Schüll it took them longer to reach victims inside casinos than it took them to get to the casino itself). The space is rather like a city, with gridded blocks of machines occasionally opening into wide, circular “plazas”, in the centre of which are slot machines ringed around columns.

      In these spaces, the ceilings are slightly recessed, mirroring a circular pattern in the rug. “Your mind sort of drops imaginary lines down,” Schüll says, “and you have a sense that you’re being protected. It helps differentiate the space, rather than having it feel like one giant warehouse.”

      Resorts World is, in essence, a locals’ casino. Its slot machines average more than $370 a day in revenue each, more than twice the take of Vegas machines. While there are some vague gestures towards New York City theming (odd, as the casino is already in the city), this is not a haunt for high-rolling “action” gamblers, as the industry calls them – live games are still illegal in New York. This, rather, is a sanctuary for “escape” gamblers, the kind who are more interested, Schüll says, in spending time on a machine than in getting big wins. “Some people want to be bled slowly,” an executive of the so-called “Costco model” of gambling says. And while there’s a Sex And The City slot machine, there are more rolling walkers than Manolos in view among the crowd, which tilts older – and, this being Queens, Asian.

      As we pause before a video poker machine, I see how deeply this “smoothing the ride” idea goes. Slipping in a $20 bill, I press the large “deal” button. But it’s not one hand of poker I’m playing – it’s 10. Some machines go up to 100. “You’ll see screens with these tiny decks,” Schüll says. “It’s parsing what was formerly a volatile risk – you either won or you lost.” And, indeed, in those 10 hands, a winning hand of two pairs shows up. “It’s insurance,” she says of the multiple decks. “Disappointment insurance.” Your overall stake may be slowly sliding away, but there’s always the hint of the win, somewhere. “Positive reinforcement hides loss,” a game designer told Schüll. “As the market is saturated with casinos, you don’t want to burn your market out,” Schüll says. “You want to keep them coming back. And to get most of their money, you need to let them have most of it back for a longer time.”

      “… By the late 1990s, Schüll notes, machine games were generating twice as much revenue as all “live games” combined; by 2003, an estimated 85% of the industry’s revenue came from machines (in the UK, revenues from so-called fixed-odds betting machines now exceed casino revenues). Schüll says that the machines, whose “old lady” image left them untouched by associations with vice, were the perfect vehicle for gambling’s expansion from a Vegas novelty to part of the fabric of everyday life everywhere (decades of experience with video games, and screens in general, didn’t hurt either, she adds).

      The games themselves were undergoing an evolutionary change … most of them targeted around breaking down those moments of inertia – just as decades of Taylorist efficiency had done on the assembly-line floor. The lever was dispensed with … Stools were added, then increasingly ergonomic chairs. Reels could be spun by pressing a button (thus doubling, Schüll says, the average number of games that could be played per hour, from 300 to 600). “Embedded bill acceptors” eliminated the need to fumble for coins, speeding up play another 15% and increasing the amount played by 30%. “Ticket in/ticket out” systems got rid of the need to dispense coins as winnings; as one slot floor manager told Schüll, “People didn’t want to wait to be paid off, because even if it took just three minutes, to them it felt like 20 minutes.” There was a curious paradox at work here: as the games got faster, players stayed on longer …

      The whole point, Schüll says, is “smoothing the ride”, allowing the casino more effectively to manage its risk (by holding out an infinitesimal mathematical hope to the player that they might “strike it big”), while keeping the player engaged by dangling “near misses” that will not, statistically, actually occur as much as our eyes might believe they would. The goal is to entice them to play close to “extinction”, the rather unfortunate industry term for a player who’s gone broke. To further the actuarial vibe, frequent players are assigned a “predicted lifetime value” by the casino modellers, a phrase that reminds us that in the gaming industry, the “product” is the person sitting at the machine.

      We pause in front of a Cleopatra slot machine, a popular “five-reel” multi-line machine designed by industry giant IGT, replete with a panoply of ankhs, asps and other orientalist symbology. There are five reels, which of course are not really reels, and no “legacy lever”. Winning is not merely a matter of lining up a few sets of cherries; rather, as laid out by a tangled diagram resembling the London tube map, there seem to be an infinite array of ways to win – the so-called “Australian model” of machine gambling. It is, strictly, a “penny slot”, meaning the $20 bill I slide into the machine translates into 2,000 credits. Don’t let the name fool you – penny slots generate upwards of 50% of all profits, and no one plays a penny; instead, you bet in chunks of 50 or 100 credits, or “bet max”. This is one of the many subtle behaviour manipulations that are going on here; what’s the harm when you’re betting a penny? (In fact, Schüll says, players end up spending more on the small-denomination machines.) As my money is accepted, a husky female voice intones: “May my luck be upon you.” I press a button, the reels spin. As they come to a stop, a rising crescendo of sound alerts me that I have won – though it takes me a minute to realise where, amid all the permutations. Even before the LED counter has finished ticking off my winnings, I can press “bet max” again to interrupt the process. As a representative of Bally, the gaming company, observed: “A gaming machine is a very fast, money-eating device. The play should take no longer than three and a half seconds per game.”

      Schüll compares it to psychologist Mihaly Csikszentmihalyi’s famous concept of “flow,” that engrossed state in which time seems to vanish. Flow, the theory goes, requires a number of preconditions: a clearly defined goal; quick feedback on whether or not the goal has been attained; and a sense of operational control over the activity. All of this is present here, and what it adds up to, Schüll says, is a greater propensity for gambling addiction. She quotes studies noting that machine gamblers – even those who had previously played other games without problems – became addicted three to four times more quickly than others (one psychologist compares it to crack cocaine) …”

      For this entire Guardian article please see:

    3. Virginian Avatar

      I live in Bristol. There are no casinos on either side of the state line. Bristol, Va. just voted to approve a casino for the Bristol Mall site but that is still at least a year away.

      1. I’m sorry. I misread a headline and thought Steve Johnson had already built one on the Tennessee side.

    4. Steve Haner Avatar
      Steve Haner

      There is no casino yet. It was just voted on a month ago. Maybe an off track betting parlor?

  2. Nancy_Naive Avatar

    Because free market medicine is a joke?

    1. Matt Hurt Avatar

      To what degree should medical outcomes for a given population be attributed to the medical system, and how much to the health choices/lifestyles of individuals in that population?

      1. Nancy_Naive Avatar

        I dunno. Want to pass anti-obesity laws? Legalize pot and put tobacco on the schedule in its place? I’ll drink to that!

  3. Baconator with extra cheese Avatar
    Baconator with extra cheese

    Maybe these diabetes problems are related to the fact most of the people in SW Virginia live in food deserts…. or does Dr Governor Coonman and the woke administration only care about food deserts in the inner city?
    I laugh when I hear about food deserts in cities… usually the people may live maybe 1.5 miles from a grocery store. Where I grew up in Appalachia the closest grocery store was about 30 miles away…. in the western and rural praire states I bet its pretty common to be 50 miles from one…. and in Appalachia we didn’t have bus service.
    Mountain Dew, Funions, elephant ears, hot dogs, and chipped ham aren’t exactly health food. But it is heart warming they can now spend their SSI checks on blackjack instead of meth.

    1. Steve Haner Avatar
      Steve Haner

      Easy walk from my grandparents’ house down to the A&P…..never drove it once. My grandfather had friends who supplied produce, even hams. My grandmother’s cooking was usually based on wholesome, fresh ingredients, but Crisco was then liberally applied and the benefits dashed…..

  4. Carol Bova, have you tried a FOIA and see what response you got? That is odd. Sounds like they’re hiding something, much like the LTCF’s and Eastern Shore Poultry Plants.

    1. I think Virginia’s Letter Authorizing a Cooperative Agreement is bound by Tennessee’s action where a paid consultant, Tennessee state senator Rusty Crowe, sponsored a bill described in a Kingsport, Tennessee Times News article as intended to make “records made or received by an independent firm or individual retained by the state to monitor, review, supervise or otherwise provide oversight” of a COPA agreement exempt from the state’s public records law.” (Tennessee’s COPA is a Certificate of Public Advantage, akin to Virginia’s Certificate of Public Need.) Since SVHA made an individual the merger monitor, that could make him exempt from FOIA. So we’ll see what’s in the SVHA Board meeting packet this week about his report to the Task Force in November.

      We should learn more from the Tennessee Dept of Health statements and documents about the annual report for year ending June 2020 submitted in October. TDH does make some docs available to the public.

      1. How can our actions be bound in Virginia so as to protect out of state agreements? This is a set up if I ever saw one.
        Let us know how it goes. The VDH has already promised some docs to me on the 15th.


        1. Because the merger affects facilities in two states, each has to agree to the terms. That’s why Virginia had the Letter of Cooperative Agreement which is “an agreement among two or more hospitals for the sharing, allocation, consolidation by merger or other combination of assets, or referral of patients, personnel, instructional programs, support services, and facilities or medical, diagnostic, or laboratory facilities or procedures or other services traditionally offered by hospitals.”

          “In 2015, the General Assembly enacted Virginia Code § 15.2-5384.1 to permit cooperative agreements that are beneficial to the citizens served by the Southwest Virginia Health Authority (Health Authority)…..”

  5. Matt,
    As part of their merger application, Ballad offered to work on goals from the SVHA’s Blueprint for Health Improvement if their merger was approved. The November Task Force Meeting had an item about whether they should revise the 2016 document. Some of the items can only be addressed by the medical system, and some can be boosted by medical community efforts.

  6. Peter Galuszka Avatar
    Peter Galuszka

    So much for “free market” health care!

    1. Nancy_Naive Avatar

      Be fair. It just doesn’t work ALL of the time. Perhaps not even most.

      BTW, if BR wants to investigate something cool… HRSD aka Hampton Roads Sanitation District got hit with ransomware that wiped its billing and records. Someone probably got a Trump contribution email and clicked a link. Why not? He’s a ruination.

      1. idiocracy Avatar

        Ahh, whatsamatta, some government agency somewhere couldn’t afford backups?

        One place I worked at got hit with ransomware. Within a couple of hours, I recovered everything that was damaged off the tape backups I had configured to run daily.

        1. Nancy_Naive Avatar

          Morons probably backed up the ransomeware and reloaded it, then backed it up again.

          1. idiocracy Avatar

            They always have the most talented and skilled people in government IT, don’t they?

          2. Nancy_Naive Avatar

            Well then, let’s raise taxes to buy better.

          3. idiocracy Avatar

            Yes, so the morons in government IT can make more money being morons.

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