Ballad Health Opinion response

The Answer Is No

August 20, 2019


On August 3, 2019, the Bristol Herald  Courier published an Opinion Editorial that I wrote titled ‘Southwest Virginians Deserve Better In Healthcare Merger.’ In that piece, I shared my experience as an independent physician practicing in Norton, Virginia where I have watched the services provided since the merger of Mountain States Health Alliance and  Wellmont. I expressed my concern that Southwest Virginians are paying higher prices for lower quality and less accessible healthcare, and my fear that patient fatalities will increase due to the lack of local care during a medical emergency. I also gave examples of rising costs to patients for specific services and increased personal cost for travel to obtain access to services.


Today, a letter dated August 16, 2019 and written by Anthony Keck, Executive Vice President of System Innovation and Chief Population Health Officer for Ballad Health, was received at my clinic address in Norton Virginia, and the same letter was copied to my opponent Will Wampler III. In that letter, Ballad requests that I withdraw my Opinion Editorial. My answer is no. I stand by the editorial. My views of the healthcare merger were developed over a year of providing care in my community and seeing concerns of my patients and family members firsthand. Ballad claims that the opinion piece I wrote has“significant errors.” Ballad goes on to imply that I have shared false statements and placed them out of context. This is untrue. Ballad’s letter to me is 10 pages of corporate-speak. In it are various statistics regarding hospital admissions, emergency room visits, staffing and future plans. Comparing it to my Opinion Editorial, Ballad’s letter substitutes apples for oranges.


In particular, Ballad provides data that is system-wide and not focused on the rural hospitals in Virginia. When I say that Ballad is funneling more patients to hospitals and emergency rooms, Ballad’s response is that there are fewer “acute hospital admissions” between 2018 and 2017 and emergency room visits decreased by 3.8%. I did not address the year 2018 compared to 2017. I am addressing the present. I am also discussing patients being sent to hospitals for otherwise routine tests where the costs are higher than previously provided at local facilities. This includes imaging studies, IV infusions, procedures, elective surgeries, and specialist visits, which may have been ordered by an outpatient provider. It appears that fewer medical conditions like these are being addressed at the local facilities and are instead referred to the hospitals in the system where prices are higher. Ballad did not provide data to contradict this. 


Similarly, when I discussed concerns regarding health outcomes, I am also focused on current data and particularly on the rural hospitals that have had service closures and staff reductions. I am not interested in cherry-picked data, but in all the basic quality measures used by groups like CMS and the Leapfrog Group to measure hospital quality. Ballad’s response is my point. Many patients in rural SWVA or NETN will not have the luxury of driving to a ‘flagship’ hospital in the service area in urgent cases or cases of emergencies. Many patients cannot afford an ambulance ride there either. On a related note, my reference to trauma services is confirmed by the reduction of the trauma level classification at Holston Valley. Ballad’s letter also states that the “change is that the most highly acute traumas will be integrated at the regional trauma center”.  This also confirms my statement that highly acute and serious traumas require the most immediate care and that travel distances in Southwest Virginia preclude access to Johnson City Medical Center’s trauma level of care when immediate intervention is necessary.  Overall, my concern is that our rural communities are being left behind with these changes. Consolidation, or the moving of programs (pediatrics, trauma, cardiac, etc) to more centralized, urbanized locations has consequences, including the risk of reducing the quality of care at smaller, rural hospitals. If quality of care is not being compromised at these smaller hospitals, then Ballad should not take issue with making the short-term outcome data of these rural hospitals public.  


Ballad took issue with my concerns regarding their prices, including the pricing of vitamin D testing. The vitamin D pricing was not taken from a listing on their website but was from a bill received by one of my patients. In fact, in the editorial, I did not fully address my concerns with their billing practices. There have been innumerable circumstances of Ballad ‘requiring’ my patients with insurance to pay more than their co-pays upfront (e.g. $1000 for routine bloodwork) before any routine service is performed, then subsequently billing the patient’s insurance and then billing the patient again. If an independent audit is not established to examine these billing procedures and ensure Ballad’s prices are meeting COPA requirements in Virginia, I will volunteer to collect and analyze patient bills from community members to aid in this endeavor. Ballad should not be concerned about an audit if their procedures are industry-standard and their prices are meeting COPA requirements.

Ballad is mandated by its Virginia COPA agreement to give 100% discounts to those patients who individually earn 225% or less of the federal poverty level. Ballad, however, does not appear to be complying with this Virginia condition of its COPA. For example, Smyth County Community Hospital has filed at least one suit this year for medical bills against a young woman earning $7.25 per hour. Additionally, many patients who came to my practice in Norton, VA were those without insurance who did not qualify for Medicaid in 2018, but still could not afford Ballad’s upfront self-pay charges, despite earning less than 225% of the FPL. I also served those with high-deductible health plans who could not afford to pay for office visits or routine testing at Ballad’s clinics. Finally, my practice is one in which I did not take a salary. For the price of that one vitamin D test at Ballad, a patient could see me for unlimited visits, in-office testing, and procedures for an entire 6 months.  This was no ‘boutique’ medical practice, as Ballad claimed in today’s letter.  Evidently, more transparency is needed for medical services availability and for medical service charges responsibility.

Ballad asserted that my Opinion personally impugned the individuals that work in the various facilities and somehow “conspired.” This is certainly not called for but not surprising given the legitimacy of my concerns. I have practiced medicine in many places in the U.S. and abroad and understand health costs and policies, economies of scale and profit centers. I have never seen the overt practices my patients have encountered at Ballad Health.

I welcome the opportunity to discuss these suggestions and recent changes with Ballad physicians and health care providers. However, I see little value in talking with marketing and lobbying personnel. 


Starla Kiser MD, MPA

Original Op-Ed: