After Appalachian Hospitals Merged Into a Monopoly, Their ERs Slowed to a Crawl

By Brett Kelman, Correspondent, who joined KFF Health News after 15 years of beat reporting at three newspapers in the USA Today Network, and Samantha Liss, Midwest Correspondent, who is an award-winning journalist covering the business of health care for the past decade. Originally published at Kaiser Health News.

In the small Appalachian city of Bristol, Virginia, City Council member Neal Osborne left a meeting on the morning of Jan. 3 and rushed himself to the hospital.

Osborne, 36, has Type 1 diabetes. His insulin pump had malfunctioned, and without a steady supply of this essential hormone, Osborne’s blood sugar skyrocketed and his body was shutting down.

Osborne went to the nearest hospital, Bristol Regional Medical Center. He said he settled into a wheelchair in the emergency room waiting area, where over the next few hours he drifted in and out of consciousness and retched up vomit, then bile, then blood. After 12 hours in the waiting room, Osborne said, he was moved to an ER bed, where he stayed until he was sent to the intensive care unit the next day. In total, the council member was in the ER for about 30 hours, he said.

Osborne said his ordeal echoes stories he’s heard from constituents for years. In his next crisis, Osborne said, he plans to leave Bristol for an ER about two hours away.

“I want to go to Knoxville or I want to go to Roanoke, because I do not want to further risk my life and die at a Ballad hospital,” he said. “The wait times just to get in and see a doctor in the ER have grown exponentially.”

Ballad Health, a 20-hospital system in the Tri-Cities region of Tennessee and Virginia, benefits from the largest state-sanctioned hospital monopoly in the United States. 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.

Tennessee and Virginia have so far announced no steps to reduce time spent in Ballad ERs. 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.

According to Ballad’s latest annual report, which was released this month and spans from July 2022 to June 2023, the median time that patients spend in Ballad ERs before being admitted to the hospital is nearly 11 hours. This statistic includes both time spent waiting and time being treated in the ER and excludes patients who weren’t admitted or left the ER without receiving care.

The federal government once tracked ER speed the same way. When compared against the latest corresponding federal data from 2019, which includes more than 4,000 hospitals but predates the covid-19 pandemic, Ballad ranks among the 100 hospitals with the slowest ERs. More current federal data is not available because the Centers for Medicare & Medicaid Services retired this statistic in 2020 in favor of other measurements.

Newer data tells a similar story. The Joint Commission, a nonprofit that accredits health care organizations, collected this same measurement for 2022 from about 250 hospitals that volunteered the data, finding a median ER speed of five hours and 41 minutes — or about five hours faster than Ballad’s latest annual report.

Ballad Health spokesperson Molly Luton said in an email statement that, by holding patients in the ER, where they are observed while waiting for a bed, Ballad avoids “overwhelming” its staff. Luton said ER delays are also caused by two nationwide crises: a nursing shortage and fewer admissions at nursing homes and similar facilities, which can create a backlog of patients awaiting discharge from the hospital.

Luton added that Ballad’s ER time for admitted patients has dropped to about 7½ hours in the months since the company’s latest annual report.

“On those issues Ballad Health can directly control, our performance has rebounded from 2022, and is now among the best in the nation,” Luton said.

Luton also noted that Ballad performs better than or close to the national average on several other measurements of ER performance, including having fewer patients who leave without being treated. CMS data shows the national average is about 3%. Ballad reported 1.4% in its latest annual report.

Osborne, the Bristol council member, attributed this statistic to Ballad’s monopoly.

“Just because they aren’t leaving the ER doesn’t mean they are happy where they are,” he said. “It just means they don’t have anywhere else they could be.”

Ballad’s Big Monopoly

Ballad Health was formed in 2018 after state officials approved the nation’s biggest hospital merger based on a so-called Certificate of Public Advantage, or COPA, agreement. COPAs have been used in about 10 hospital mergers over the past three decades, but none has involved as many hospitals as Ballad’s.

State lawmakers in Tennessee and Virginia waived federal anti-monopoly laws so rival hospital systems — Mountain States Health Alliance and Wellmont Health System — could merge into a single company with no competition. 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.

The Federal Trade Commission warns that hospital monopolies lead to increased prices and decreased quality of care. To offset the perils of Ballad’s monopoly, officials required the new company to commit to a long list of special conditions, including dozens of quality-care metrics spelled out with specific benchmarks.

In its latest annual report, Ballad improved on many quality-of-care metrics over the prior year, including several that the company prioritized, but still fell short on 56 of 75 benchmarks.

ER time for admitted patients is one of those. The benchmark was set at three hours and 47 minutes in the original COPA agreement. Ballad met or nearly met this goal for three years, according to its annual reports. Then the ERs slowed.

In 2022, Ballad reported a median ER time for admitted patients of about six hours.

In 2023, it reported the same statistic at seven hours and 40 minutes.

In the latest report, ER time for admitted patients had reached 10 hours and 45 minutes.

CMS, which grades thousands of hospitals nationwide, warns on its website that timely ER care is “essential for good patient outcomes,” and that more time spent in the ER has been linked to higher complication rates and delays in patients getting pain medication and antibiotics.

Ben Harder, chief of health analysis for U.S. News & World Report, said extensive ER times can be a symptom of slowdowns throughout a hospital, including in the operating room.

“A long delay in getting patients admitted is both a risk in itself, in that a test may not get conducted as promptly,” Harder said. “But it’s also an indication that the hospital is backed up, and that there are problems getting patients moved from one unit to another.”

Bill Christian, a spokesperson for the Tennessee Department of Health, said Ballad’s rising ER times had been “noted” but did not say if the agency had taken or was considering any action. Christian directed questions about Ballad’s latest stats to the company itself.

‘A Nightmare for Community Members’

Ballad has also fallen short — by about $191 million over the past five years — of its obligation to Tennessee to provide charity care, which is free or discounted care for low-income patients, according to health department documents and Ballad’s latest report. The health department waived this obligation in each of the past four fiscal years. Ballad has said it would ask for another this year.

In a two-hour interview last year, Ballad CEO Alan Levine defended his company and said that because the Tri-Cities region could not support two competing hospital companies, the COPA merger had likely prevented at least three hospital closures. Levine attributed Ballad’s failure to meet quality benchmarks to the pressure of the covid pandemic and said charity care shortfalls were partly caused by Medicaid changes beyond Ballad’s control.

“Our critics say, ‘No Ballad. We don’t want Ballad.’ Well, then what?” Levine said. “Because the hospitals were on their way to being closed.”

Some residents see Ballad as a savior. John King, who runs a physical therapy clinic in the core of Ballad’s region, said at a public hearing last June that in multiple visits to Ballad ERs, including one for a stroke, he found their care to be quick and compassionate.

“If it weren’t for Ballad Health, I literally would not be here today,” King said, according to a hearing transcript.

Ballad’s failures to live up to the terms of the COPA agreement were detailed in a KFF Health News investigation last September, and the company faced a new wave of criticism in the months that followed.

Local leaders in Carter County, Tennessee, in October debated but did not pass a resolution calling for Ballad to be better regulated or broken up. Tennessee Attorney General Jonathan Skrmetti, a Republican, said in an interview with the Tennessee Lookout published in November that Ballad must be constantly monitored in light of community complaints. Earlier this month, Tennessee state Rep. David Hawk (R-Greeneville), who represents a region within Ballad’s monopoly, called for Levine’s resignation, according to

In response, Ballad Health said in a statement it has “strong relationships with the majority of elected officials” in Carter County and welcomed scrutiny from the Tennessee attorney general. Ballad said Hawk’s “opinion certainly does not reflect our broader relationships” within the area. Tennessee lawmakers are also considering legislation to forbid future COPA mergers in the state, which Ballad said “risks putting more hospitals at risk for closure.”

The bill was introduced by state Sen. Heidi Campbell (D-Nashville) and state Rep. Gloria Johnson (D-Knoxville), who is running for the U.S. Senate. Johnson said the bill would end Ballad’s protection from antitrust laws.

“It’s just been a nightmare for community members out there,” Johnson said. “And they have no other option.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.


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About Lambert Strether

Readers, I have had a correspondent characterize my views as realistic cynical. Let me briefly explain them. I believe in universal programs that provide concrete material benefits, especially to the working class. Medicare for All is the prime example, but tuition-free college and a Post Office Bank also fall under this heading. So do a Jobs Guarantee and a Debt Jubilee. Clearly, neither liberal Democrats nor conservative Republicans can deliver on such programs, because the two are different flavors of neoliberalism (“Because markets”). I don’t much care about the “ism” that delivers the benefits, although whichever one does have to put common humanity first, as opposed to markets. Could be a second FDR saving capitalism, democratic socialism leashing and collaring it, or communism razing it. I don’t much care, as long as the benefits are delivered. To me, the key issue — and this is why Medicare for All is always first with me — is the tens of thousands of excess “deaths from despair,” as described by the Case-Deaton study, and other recent studies. That enormous body count makes Medicare for All, at the very least, a moral and strategic imperative. And that level of suffering and organic damage makes the concerns of identity politics — even the worthy fight to help the refugees Bush, Obama, and Clinton’s wars created — bright shiny objects by comparison. Hence my frustration with the news flow — currently in my view the swirling intersection of two, separate Shock Doctrine campaigns, one by the Administration, and the other by out-of-power liberals and their allies in the State and in the press — a news flow that constantly forces me to focus on matters that I regard as of secondary importance to the excess deaths. What kind of political economy is it that halts or even reverses the increases in life expectancy that civilized societies have achieved? I am also very hopeful that the continuing destruction of both party establishments will open the space for voices supporting programs similar to those I have listed; let’s call such voices “the left.” Volatility creates opportunity, especially if the Democrat establishment, which puts markets first and opposes all such programs, isn’t allowed to get back into the saddle. Eyes on the prize! I love the tactical level, and secretly love even the horse race, since I’ve been blogging about it daily for fourteen years, but everything I write has this perspective at the back of it.


  1. Jack

    Is it possible that the the triage nurse at the Bristol hospital recognized neither DKA nor a city counsellor? (Lambert: zeugma!). In the before times, physicians holding staff privileges at a hospital would admit patients (day shift only) from their offices, so-called “direct admits”, no ER involvement. The private staff member MD would send the patient to the hospital admitting office with written orders which the floor staff executed after the patient arrived at the floor. Then, for patients who presented to the ER where I worked, the private physicians holding admitting privileges assigned themselves to one of three categories : 1) Call before the patient seen; 2)ER MD call at time of case disposition; 3) ER MD see and evaluate and write admitting orders, notify office of admission. Corporate changed this system. I was not privy to their reasons, but probably it was to eliminate what they saw as redundancies of staff function, and to capture revenue previously going elsewhere, For corporate, ER saw and admitted them all, except for scheduled admissions for OR, and a few others. This works when things are slow and the hospital well staffed, not so well in times of high demand like a pandemic. And by “well staffed”, not just nursing staff, mind, but cleaning, transport and clerical staff as well. ER then became a bottleneck. Corporate then started to skimp on all staff department levels (except their own) to “save money”. Another change was corporate’s invention, the “hospitalist”, an MD in the employ of the hospital directly, a function sold as relieving the physician of record from the work of hospital management of the patient. Another bottleneck in busy times. Management’s redundancies were staff’s reserves, and the patient throughput slowed further. These corporate changes failed in the pandemic, neoliberal corporate management-think is to blame here as well. KFF soft-pedals these facts. The states are right to take action. Get moving!

  2. GDmofo

    “Some residents see Ballad as a savior. John King, who runs a physical therapy clinic in the core of Ballad’s region, said at a public hearing last June that in multiple visits to Ballad ERs, including one for a stroke, he found their care to be quick and compassionate.”

    Totally unbiased.

    Could they not find a less biased source in favor of this vampire?

  3. Arkady Bogdanov

    I am late again, as is often the case. This is very similar to what we have seen in north central and western Pennsylvania. Where we once had non profit community hospitals that were controlled by people who lived within the communities, these small hospitals were all taken over by University of Pittsburg Medical Center (UPMC) seemingly overnight- very shady. UPMC is also a non-profit, but it was disturbing how they just appropriated all of what was essentially community-owned infrastructure so quickly and without any public input. Quality of service has nosedived. Those who can are now traveling across the border to NY to get their care from a different system (1.5 hours in the case of my parents). For a while UPMC even denied all forms of insurance, except their own, however that practice was stopped- which I assume happened because someone complained to a regulator.

  4. 2serve4Christ

    “I’m A Doctor: Corporate Greed Is Killing Your ER”
    Mar 18, 2024 | 11 minutes
    Private equity is swallowing up America’s emergency rooms. 1 in 4 ERs are now staffed by private equity-based firms. The waits are longer, the bills are higher, and ER doctors are being replaced by lower-paid contractors.

  5. nellperkins

    If he heads to Knoxville hoping for shorter ER wait times, he won’t get them. I wish I didn’t know this, but I do. The hospitals in Knoxville are also on the verge of collapse.

  6. Luke

    Nursing shortages at a facility IMO can be expected to be most of all caused by staffing ratios. Pay is only the second most important issue. The regulatory agency in question should be informing those hospitals what those ratios should be (and appropriate pay for nurses, if they can’t figure that out on their own).

    Of course, ER wait times would be MUCH reduced most places by just transporting all illegals to the border, and/or billing their country’s nearest consulate for the cost of their care plus 20%, on pain of confiscation of their embassy and consulates, along with all foreign aid, trade credits, remittances, and bank accounts held by all their nationals here if not paid in full within 30 days. (The citizens of that state NEVER agreed to have their taxes or medical insurance deductions diverted to care for nonAmericans, which makes so spending them that way criminal misappropriation.)

    That makes those excellent ideas.


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