The Ballad COPA hearing is tonight. Here's what the public said last time.

Editorial Note: The public hearing about Ballad's COPA will take place 5:30-7:30 p.m. Tuesday, Nov. 18 at the Northeast State Community College Center for the Performing Arts in Blountville. Those who can't attend can provide input by emailing tn.health@tn.gov. Six Rivers Media will livestream the hearing on the Times-News Online Facebook page. The long-awaited public hearing about Ballad Health's Certificate of Public Advantage, hosted by the Tennessee Department of Health, is tonight. As people say their piece about the state-sanctioned health care system, attendees can probably expect to hear complaints about emergency room wait times, quality of care, patient safety and a health care monopoly. They may also hear about the many investments Ballad has made into other health-related groups and projects around the region. These were all common complaints and comments at the last hearing in August 2023. In preparation for the upcoming meeting, Six Rivers Media reviewed more than 70 publicly-available comments from that hearing, including both the transcript from the in-person meeting and other comments submitted online. Here's what we learned. Troubling patient stories, concern from physicians Nearly 50 people, about two-thirds of the commenters, shared concerns or negative views about Ballad Health and the COPA. The top concerns involved patient care and safety, mostly in connection to emergency room care and closures at Holston Valley Medical Center in Kingsport and Sycamore Shoals Hospital in Elizabethton. At that time, it had been several years since the Holston Valley neonatal intensive care unit had closed and its Level I trauma center consolidated and moved to Johnson City Medical Center. Just a few months before the hearing, Ballad had also closed the intensive and progressive care units at Sycamore Shoals Hospital. Those units were also consolidated to the Johnson City hospital. Many individuals submitted personal testimonies of their own or a loved one's time spent in a Ballad emergency room. The idea that Ballad's care was akin to health care in a third world country was mentioned at least four different times. One patient wrote to the health department while on her third day lying on a gurney in an open room with a handful of others at the Johnson City Medical Center: "We all share one bathroom. We are all on gurneys separated by curtains," she wrote. "I am sure [HIPAA] laws are being broken as I can tell you the age, living conditions, number of surgeries, medical conditions, and the medications the lady next to me is on. All I need now is her social security number." Another woman detailed her father's death at Holston Valley. She said he waited about nine hours in the ER waiting room. It was unclear if anyone checked on him or provided food or water during that time. When he had a heart attack in front of her, she said no one came. He died a few days later. The stories weren't limited to patients. About a third of the commenters had worked in health care at some point, either with Ballad or at a private practice. One former Ballad nurse said after the merger, hospitals were understaffed and patient ratios grew "higher than ever." She said nurses were told to start patient care in the ER waiting room. If patients left, nurses were told to note that they left against medical advice — even though they weren't told about the risks of leaving. "Ballad employees are fearful to speak up due to the monopoly [Ballad has] created, fearing there is nowhere else to work," she added. Other physicians were displeased with changes to Ballad's terms of certification. The document sets the standards that determine if the benefits of the COPA outweigh any disadvantages. Over time, revisions of the agreement limited the duties of a local advisory council and eliminated a provision that kept Ballad from opposing health care competition. Wally Hankwitz, a retired health care executive and consultant, submitted an informal analysis determining that Ballad had not met the COPA's standards at the time on clinical, safety and patient survey measures. As reported by KFF Health News, this document impressed former Tennessee Health Commissioner Ralph Alvarado. "THIS communication from the COPA hearing is particularly good," Alvarado wrote in a July 2023 email to his staff. "Totally based on data. I would almost like to hear Ballad's response to this." Some commenters have the same concerns more than two years later. Dr. Joni Sago, a dermatologist with the private practice Dermatology Associates, detailed her patients' concerns about Ballad costs and ER overcrowding in her letter for the last hearing. At the time, she said patients deserve better. In a recent email to Six Rivers Media, she said her opinion hasn't changed much. Bill Spooner, a retired health care executive and technology advisor, said his concerns are also similar to ones he expressed in 2023. At the time, he complimented Ballad on its implementation of a new electronic record system and a unified message during the COVID-19 pandemic. He also wrote that Ballad could learn a few lessons, specifically regarding the Sycamore Shoals ICU closure. "Greater public input should [be] sought before the decision, even when Ballad has concluded that the change is necessary," he said in 2023. "Ballad could consider its response to various items of criticism more carefully and compassionately… Sometimes it plays better not to be the smartest one in the room." Group support, individual concerns The comments about Ballad weren't all critical. But those who spoke positively about the health care system — about a third of commenters — spoke about Ballad's investments in the region and other groups. Out of those 25 commenters who shared positive views, around three-fourths of them (18 people) spoke on behalf of a group that had some sort of partnership or financial connection with Ballad. Others noticed the trend. "I appreciate the open public forum," one private practice physician president wrote, "but was disheartened at how much time was spent discussing Ballad's philanthropy at the expense of discussing its healthcare delivery—its highest priority." The investments from Ballad into the region's health resulted in tangible improvements to health, according to commenters. Speakers from Greater Kingsport Family YMCA, STREAMWORKS and an Appalachian School of Law and Virginia Tech program said Ballad support was integral to feeding hundreds of children, providing STEM education and giving free legal services to hundreds of low-income patients. In one email thread, King University Vice President for Academic Affairs and Provost Dr. Matthew Roberts and School of Nursing Associate Professor and Dean Donna Fraysier noted Ballad's investments in its nursing program. With a Ballad donation, Fraysier wrote, the school was able to buy a simulation birthing mannikin to train students. While asking for speaking points on the benefits of Ballad partnership in that same thread, Roberts wrote: "I have to go play the glad game!" The glad game, made popular by American literature character Pollyanna, is a mindset practice where someone looks for something to be glad about, no matter how difficult the situation. Ashley Hartless, the university's interim associate vice president for marketing, noted in an email to Six Rivers Media that no university representative delivered public comments in person at the meeting. She added that King is "pleased to have Ballad as a long-time partner to provide clinical training experiences for our nursing students," as mentioned in the 2023 submitted comments. What do Ballad and the health department say? In an on-the-record conversation with the Six Rivers Media editorial board in August, Ballad Chairman and Chief Executive Officer Alan Levine acknowledged frustration from the public. "There are people who do have legitimate complaints when they experience Ballad," he said. "We want to know those and we want to verify the facts and we want to work with those patients to learn what we can." It's a sentiment echoed by Tennessee Department of Health spokesperson Bill Christian. "The Department values all input from the public regarding the COPA whether it's through public hearings or submitted comments," he wrote in an email to Six Rivers Media, adding that the department fields and responds to all COPA-related comments received throughout the year. Levine also addressed commonly-cited complaints about unit closures and low star ratings from the Centers for Medicare and Medicaid Services. Consolidating trauma centers resulted in better outcomes, he said, referencing an external March 2024 study of Ballad's consolidation. The study — which surveyed around 2,800 patients before consolidation and around 3,800 patients after — found that while the Johnson City Medical Center saw a higher volume and more severe cases after consolidation, there was no overall change in deaths. It also found a decrease in deaths for patients who needed the ICU and surgery. "Once you make the hard decisions and people do get angry, time goes by and the data will show whether those decisions were the right decisions or not," Levine said in August. "And I think we're now starting to see where the data is showing that they were the right decisions." Regarding low CMS star ratings for Ballad hospitals, Levine noted that he disagreed with the government's aggregation of complicated data into one simple rating. Recent studies have found that the star ratings are restricted. For example, they're sensitive to changes in calculation and are limited in measuring surgery quality. They're also rated based on data that is months or years old. The alternative to the 2018 merger that created Ballad Health, Levine said, was possible acquisition by an outside entity. "The change became do we allow ourselves to be acquired by outside entities, and therefore the health care in this region be controlled by outside entities," he said, "or do we decide to create our own path, knowing that there were going to be a lot of very difficult decisions that had to be made?" Ballad representatives did not respond to further requests for comment by press time.