303 Med Tech Parkway

Johnson City, TN 37604

balladhealth.org

August 16, 2019

Starla Kiser, MD
5516 Industrial Park Road
Norton, VA 24273

Dear Dr. Kiser:

My name is Tony Keck, and I serve as the Chief Population Health Officer for Ballad Health. Among other
responsibilities, I provide oversight to our government relations program. We work closely with our
legislative delegation to support many initiatives to help improve the lives of individuals in Southwest
Virginia, including bringing a new dental residency program to Johnston Memorial Hospital, expanding
access to healthcare for thousands of low-income residents in Southwest Virginia, and fighting the opioid
epidemic.

While you have not asked to meet with Ballad Health to learn more about these initiatives, I would like
to invite you to do so. As a former state health official for Governors Bobby Jindal in Louisiana and Nikki
Haley in South Carolina, I consider it critical that government officials (and candidates for those positions)
be armed with accurate information that they can share with the public. We also extend this invitation
to your opponent, Mr. Wampler, who is copied on this letter.

Having also read your recent opinion piece in the Bristol Herald Courier, I would like to take an
opportunity to correct several significant errors contained within your letter. While certainly there will
be people who do not agree with various policies or initiatives related to Ballad Health’s COPA and
Cooperative Agreement, the debate is not a place to repeat statements that are easily verifiable as false
or out of context. As your letter has now become a paid campaign post on Facebook, we ask that you
please withdraw it, given its many inaccuracies.

We have listed below the portions of your letter that contain factual inaccuracies, organized by category,
including false statements on the subjects of patient referrals, trauma care, surgical services, rural
healthcare, hospital staffing, healthcare quality, healthcare pricing, and the organizational structure of
Ballad itself.

Patient Referrals
• Your statement that “Ballad….is funneling more patients to hospitals and emergency rooms”
is not true. Last year Ballad Health had 5,085 fewer acute admissions to our hospitals than the
prior year. Emergency Room visits decreased by 3.8 percent. This decline far exceeds the
population decline in the region and is largely due instead to the deliberate work of Ballad Health,

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 in partnership with physicians and community resources, to reduce unnecessary lower-acuity
admissions, readmissions and emergency room visits.

• Each quarter, in filings with the Municipal Securities Board readily available to the public, we have
reported on our efforts to reduce lower acuity admissions. In fact, last quarter we reported that
our readmissions were at the lowest level in the history of both legacy health systems (Mountain
States and Wellmont).

Trauma Care
o You state that Ballad is “planning to regionalize bread-and-butter” health services by “closing”
trauma at Holston Valley and the surgical program at Mountain View, and then imply that heart
attacks, strokes, and acute abdominal issues will no longer be treated “expediently.” There are
several problems with these statements that concern me, because perpetuating falsehoods on
this subject has the potential to cause patients to make poor choices in an emergency situation,
which can be harmful or even fatal. Please note the following corrections:

o You state trauma services at Holston Valley are being closed, which is not true. Holston
Valley Medical Center is being reclassified to a Level III trauma center and will continue to
provide most of the trauma capabilities it has today. Ninety percent of the trauma cases
currently seen at Holston Valley will continue to be served there.

o Even with the trauma changes announced, approximately 99.6 percent of all cases currently
treated in our emergency departments will continue to be treated in their community
hospitals. Furthermore, your comments fail to acknowledge the rules imposed by the Virginia
Department of Health through the Virginia Cooperative Agreement, where Ballad is required
to maintain access to emergency services in the communities where we currently operate.

o The suggestion that “Trauma” is a “bread and butter” service is not accurate and is
misleading to the public. Trauma is a service very few hospitals offer, and typically, trauma
centers are highly regulated by states to ensure there is not a dilution of trauma services. The
only change is that the most highly acute traumas will be integrated at the regional trauma
center.

o Importantly, Ballad Health has committed to seeking American College of Surgeons

Committee on Trauma verification for our Level I trauma center. The ACS Committee on
Trauma is responsible for verifying that a trauma center has the necessary resources for
delivering optimal trauma care. As a guide, it uses the Resources for Optimal Care of the
Injured Patient. Neither system had received this verification prior to the merger.

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 o Many of the people you seek to represent have safely utilized the trauma services in Johnson
City for many years. For reference, the entire Commonwealth of Virginia has six adult Level I
trauma centers. Our region will continue to have the most robust trauma coverage in either
Tennessee or Virginia. Information regarding the location of trauma centers in Virginia is
easily accessible on the Virginia Department of Health Website.

o Your letter promotes the common misperception that heart attacks, strokes, and acute
abdominal issues are trauma – this is incorrect. Ballad Health will continue to treat these
conditions, including most other orthopedic injuries, poisonings, and other emergencies at
our hospital emergency departments the same as they are today. In fact, you may have seen
a recent story where a patient in Wise County credited the work of our emergency room at
Norton Community Hospital with saving the life of her grandmother. I would urge you to help
support your local emergency rooms, as their capabilities are astonishingly advanced. They
perform trauma stabilization, heart attack care, stroke care, and now that Ballad Health has
recruited an orthopedic surgeon to Norton, they can provide enhanced orthopedic care.
Ballad Health has also recruited a cardiologist for Norton, who now provides cardiology
support for the emergency room.

Surgical Services
• While your statement about the closure of surgery at Mountain View is factually correct, had you
contacted us before writing your letter you would have found:

o Surgical volumes in Wise County have actually increased by 18 percent, meaning fewer
patients are now traveling out of the county for surgery. In addition to this enormous
benefit, keeping more cases in the hospitals locally helps sustain the hospitals financially and
helps staff maintain their skills, contributing to better outcomes.

o In a county with no population growth, how is surgical volume increasing? Prior to the
merger, neither legacy health system would permit its physicians to cover the competing
hospital. Given the limited number of physicians in Wise County, this meant that coverage
was limited when doctors were out of town and patients would be sent to Kingsport or
Johnson City when they had certain medical needs. Now, the physicians are working
together, and they provide more consistent coverage.

o Low volume surgery hospitals, like Mountain View, can actually pose risk to patients, and
the evidence shows integrating the volumes at a higher volume hospital leads to better
outcomes for patients. There is significant peer-reviewed evidence that supports the
practice of ensuring surgical volumes are high enough to sustain quality, and three separate
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 surgical programs in a single county of 40,000 residents does not reach this standard. Here
are some relevant and readily available resources:
 https://www.usnews.com/news/articles/2015/05/18/risks-are-high-at-low-
volume-hospitals
 http://www.healthcarebusinesstech.com/surgery-low-volume-hospitals/
 https://www.leapfroggroup.org/ratings-reports/surgeon-volume-and-
surgical-appropriateness

o Had you spoken with us prior to writing your letter, you would have learned that that the
physicians on our medical staff encouraged the consolidation of surgical services. They and
their patients were already largely choosing to perform their elective surgeries at Lonesome
Pine and Norton Community Hospital. In July and August 2018, only 10 surgeries were
performed at Mountain View each month. In September, there were none, and in October
there were only two. Our decision to suspend the surgical services at Mountain View
followed the physicians’ decision to perform their elective cases at the hospitals with higher
volumes.

Rural Healthcare
• Contrary to your “alarm” of less accessible health care resulting from Ballad’s merger, the truth
is while rural hospitals are closing across the United States leaving many communities with no
services, Ballad Health has invested in facilities, personnel and programming to increase access
in the region. For example:

o In October 2018, Ballad opened a new 40,000-square-foot hospital facility in Unicoi County,
Tennessee, replacing an aging facility that was originally constructed in 1953. 1
o In January 2019, Ballad announced that it would be reopening a shuttered hospital in Lee
County, Virginia designed to meet the needs of the community. 2 The capital investment in
this facility is expected to be as much as $15 million over the next two years. 3
o Ballad Health also announced a new dental residency program in Southwest Virginia, the
funding of a new master’s program in addiction counseling in partnership with Milligan
College, and an addiction medicine fellowship program at East Tennessee State University’s

1
Ballad Health Opens New Hospital in Erwin, The Business Journal of Tri-Cities Tennessee/Virginia (October 23, 2018),
http://bjournal.com/ballad-health-opens-new-hospital-in-erwin/ .
2
Ballad Health reveals plans to reopen Lee County, VA hospital (January 30, 2019), News Channel 11 WJHL,
https://www.wjhl.com/news/local/ballad-health-reveals-plans-to-reopen-lee-county-va-hospital/ .
3
Lee County hospital reopening is reason Ballad was created, CEO says (January 30, 2019), Johnson City Press
https://www.johnsoncitypress.com/Health-Care/2019/01/30/With-plan-to-open-Lee-County-hospital.

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 Quillen College of Medicine, each of which will produce much needed clinical capacity in
Northeast Tennessee and Southwest Virginia.4 5 6

Hospital Staffing
• You state that “program closures and staffing cuts at hospitals, combined with personnel
voluntarily leaving since the merger, have resulted in severe staffing shortages.” As a physician,
you are certainly aware of the national nursing shortage, and as a candidate in a rural region, you
are also aware that the nursing shortage disproportionally affects rural areas. 7

• According to multiple sources, that shortage will exceed 800,000 nurses next year 8, and more
than one million by 2024. 9 The U.S. Health Resources and Services Administration (HRSA)
projects that Tennessee will not be able to meet more than half of its nursing demand by next
year and a review of the national data demonstrates that nursing turnover is at the highest level
in more than a decade. 10 11

In the face of this national crisis, had you spoken with us, you would have learned that:

o Notwithstanding the national nursing shortage, Ballad Health’s nursing turnover has
actually decreased in the last year.
o We have not cut nursing positions, and in fact we are actively hiring nurses. We support
nursing rotations and programs throughout the region.

4
Our View: Dental program would bring care to needy patients, Bristol Herald Courier (April 28, 2019)
https://www.heraldcourier.com/opinion/our-view-dental-program-would-bring-care-to-needy-patients/article_9f37a6a0-
008a-58ea-9c02-52dcd4ed1bbe.html
5
Milligan announces addictions counseling concentration, Johnson City Press (June 9, 2019),
https://www.johnsoncitypress.com/Health-Care/2019/06/09/Milligan-announces-addictions-counseling-concentration
6
Ballad Health, ETSU partner to create addiction medicine fellowship (June 6, 2018), https://www.etsu.edu/news/2018/06-
jun/nr_addiction_medicine_fellowship_program_application.aspx
7
Health Care Workforce Distribution and Shortage Issues in Rural America. National Rural Health Association. (January
2012) https://www.ruralhealthweb.org/getattachment/Advocate/Policy-
Documents/HealthCareWorkforceDistributionandShortageJanuary2012.pdf.aspx?lang=en-US
8
The Future of the Nurse Shortage: Will Wage Increases Close the Gap? Health Affairs. (November/December 2003)
https://www.healthaffairs.org/doi/pdf/10.1377/hlthaff.22.6.199
9
2019 National Health Care Retention and RN Staffing Report. NSI Nursing Solutions, Inc. (2019)
http://www.nsinursingsolutions.com/Files/assets/library/retention-
institute/2019%20National%20Health%20Care%20Retention%20Report.pdf
10
TN facing long-term shortage of health care workers. Tennessee Ledger. (May 17, 2019)
http://www.tnledger.com/editorial/ArticleEmail.aspx?id=117709&print=1
11
2019 National Healthcare Retention and RN Turnover Report. NSI (March 2019),
http://www.nsinursingsolutions.com/Files/assets/library/retention-
institute/2019%20National%20Health%20Care%20Retention%20Report.pdf

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 o Ballad recently provided nurses and key clinical support staff $10 million of additional
annual compensation. 12 This was equivalent to Ballad Health’s entire operating income from
last year.
o Where Ballad Health has, in fact, reduced jobs, it was among our administrative ranks.
Immediately after the merger in early 2018, approximately 200 administrative positions were
eliminated, primarily in Tennessee, reducing the cost of healthcare in the region by millions
of dollars. As a result of attrition and efforts to match staff with other open positions, while
those reductions did occur, in its first Annual Report, the Tennessee Department of Health
stated that there have been fewer layoffs post-merger than had been expected. 13
o Since the closing of the merger, Ballad Health has recruited more than 150 new physicians
and Advance Practice Providers to serve the region. Successes include the recruitment of
cardiology in rural Wytheville, VA, and Norton, VA; nephrology in Abingdon, VA; urology in
Kingsport, TN; as well as neurology, orthopedics, pain management, hospitalists, psychiatry,
and other needed specialties throughout the region. Importantly we are utilizing those
physicians more effectively. Cross coverage of hospitals has increased, and restrictions on
medical staff privileges have been eliminated.

• You should also know that Ballad Health has been one of the most active health systems in the
country fighting for a change to the Medicare Area Wage Index, which has harmed rural hospitals
for more than 20 years. In fact, Ballad Health’s chairman and CEO, Alan Levine, recently testified
before the US Senate, advocating for improvements that would help rural hospitals.14 Mr. Levine
specifically advocated for the federal government to address problems with the Medicare Area
Wage Index. Rule changes to the AWI were recently approved by CMS, and these changes will
bring significant additional resources to support nursing and other medical professionals
throughout rural America, including Virginia and Tennessee. 15 While we are not aware that you
have made any such advocacy, it may be helpful for you to join us in future efforts as we seek to
alleviate the staffing shortages and help support our rural hospitals. Here is a link to Mr. Levine’s
written testimony submitted for the record:

https://www.balladhealth.org/news/levine-senate-testimony-rural-healthcare

12
Ballad Health announces pay raises for nurses, The Business Journal of Tri-Cities Tennessee/Virginia (May 7, 2019),
http://bjournal.com/ballad-health-announces-pay-raises-for-nurse/
13
Certificate of Public Advantage 2019 Department Annual Report, Tennessee Department of Health (May 7, 2019),
https://www.tn.gov/content/dam/tn/health/documents/copa/2019-Department-Annual-Report-FINAL-2019.05.07.pdf
14
Ballad Health Executive Chairman Alan Levine testifies to the Senate Committee on Health, Education, Labor and
Pensions at a hearing entitled "Health Care in Rural America: Examining Experiences and Costs." C-SPAN (September 26,
2018) https://www.c-span.org/video/?c4751429/alan-levine-testimony
15
Federal government to increase money to rural in exchange to cover care costs. WJHL (August 3, 2019)
https://www.wjhl.com/news/local/federal-gov-to-increase-money-to-rural-hospitals-in-exchange-to-cover-care-costs/

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Healthcare Quality

• You state without evidence that quality had diminished as a result of the merger. In fact, driven
by clinical leadership and the contributions of physicians and team members across the system,
Ballad Health has seen significant improvements in objective quality measures since the
creation of the system.

• Recently, US News reported that all four of Ballad’s flagship hospitals – Johnson City Medical
Center, Holston Valley Medical Center and Bristol Regional Medical Center, in Tennessee; and
Johnston Memorial Hospital in Virginia, are among the top performing hospitals in Tennessee
and Virginia in several specialties, with each hospital providing “Top Performing” services and
programs in Heart Failure and COPD in both states. In each state, less than 30 percent of all
hospitals had any top performing programs, according to US News. In Tennessee, all three of
Ballad Health’s flagship hospitals had top performing programs. In Virginia, Ballad Health’s
flagship Virginia hospital also had top performing programs. 16

• Additionally, in the US News rankings, Bristol Regional Medical Center and Holston Valley Medical
Center moved up in overall rankings from tied to #10 in Tennessee last year to tied #7 this year. 17

• In partnership with physicians and clinical staff, Ballad has seen a focused effort on quality
improvement pay off for patients. Specific examples include:

o Ballad Health reported zero infections for abdominal hysterectomy cases across the
system
o 47 percent reduction in pressure injury rate
o 39 percent reduction in iatrogenic pneumothorax rate
o 13 percent reduction in central line bloodstream infections
o 42 percent reduction in clostridium difficile infections

Healthcare Pricing

• Your commentary about pricing is questionable. Pricing increases occur among virtually all
hospitals in the nation as a result of the increased cost of providing care. For example, the cost
of drugs purchased by Ballad Health last year increased by almost 15 percent. Changes in our

16
Best Hospitals by State. U.S News and World Report (accessed August 16, 2019) https://health.usnews.com/best-
hospitals/area
17
Best Hospitals by State. U.S News and World Report (accessed August 16, 2019) https://health.usnews.com/best-
hospitals/area

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 prices are not a result of the merger. The early evidence points toward the merger’s promise of
controlling prices better than would have otherwise occurred.

• In its end of year analysis, the State of Tennessee found that Ballad Health has complied with
the price caps and other restrictions set in the Tennessee COPA (also included in the Virginia
Cooperative Agreement), a cap which by design produces price increases lower than the national
average for hospital and medical services. In fact, the caps are set below the Hospital Consumer
Price Index and indexed instead to the Medicare market basket. By definition, this means Ballad
Health’s pricing must stay below the pricing increases of other hospitals that are not regulated
by a COPA or Cooperative Agreement.

• In the past year, Ballad Health has announced it was one of only 21 Accountable Care
Organizations in the nation to help Medicare achieve cost savings in each of the first several years
of the program – saving taxpayers more than $20 million while maintaining high quality. Ballad
is expanding this program from legacy Mountain States to legacy Wellmont physicians, which will
double the number of participants in this risk-based program, a stated goal of the
Commonwealth of Virginia.

• Recently, the Mayor of Washington County, Tennessee, released data demonstrating that county
employee healthcare costs have decreased by 10 percent due to efforts by Ballad, BlueCross
BlueShield of Tennessee, and the county to provide better access to care and better care
management.

• Finally, your comparison of certain Vitamin D pricing is misleading. Hospitals nationally are
required to post chargemaster pricing, which we have complied with. As we state on our website,
the posted pricing is not reflective of what is actually paid by insurers, employers or our patients.

• What is paid is determined based on a variety of factors, including insurance coverages and
discounts, whether the patient falls within our policy of free care for low income patients (where
they pay nothing for their health care services), and whether the patient is covered by Medicare
or Medicaid (the overwhelming majority of our patients are covered by Medicare and Medicaid,
and our posted pricing is totally irrelevant to those patients, as Medicare and Medicaid set rates
that we cannot negotiate).

• The reality is that many individuals in the region you wish to represent have Medicare or
Medicaid as their insurance. There are many thousands more with no insurance at all. After calls
to your practice and review of your website, we understand that your personal practice requires
patients to pay cash, and does not accept Medicare or Medicaid. Ballad Health is committed to
serving all patients regardless of their ability to pay. In fact, as a result of the merger, Ballad

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 Health increased its charity care policy, which now provides individuals and families up to 225%
of the federal poverty level free care (up from 200% prior to the merger), resulting in access for
thousands more individuals region-wide. Individuals and families above 225% of the FPL up to
400% are eligible for major discounts based on a sliding scale.

• Based on these factors, your patients may actually pay more out of pocket than many patients
pay at Ballad Health, where we do accept insurance, and unlike your own clinic do not have
“waiting lists” to access free or discounted care.

Our Organizational Structure and Finances

• You state that Ballad reported $66 million in first quarter revenue. You read our financials
incorrectly. Our first quarter operating revenue of fiscal 2019 was $519.8 million. Importantly,
that translates to annual investments of more than $1 billion of salaries, wages, and benefits
supporting more than 15,000 team members and their families, making Ballad the largest
employer in the region. As a not-for-profit, we reinvest revenues in excess of our expenses back
into the community. Almost 1,000 team members plus hundreds of additional community
physicians and community leaders on hospital medical staffs and community boards make up the
leadership of Ballad Health. It is disturbing how carelessly you impugn these individuals, many
of whom work and live in your district, with your accusations of a conspiracy to line our collective
pockets by making care more expensive and less accessible.

• Finally, your statement that “Mountain States Health Alliance took over Wellmont” is without
merit. This was a merger of equals painstakingly negotiated and voted on unanimously by the
independent boards of the two legacy organizations. The current board membership is
composed equally of former Mountain States and Wellmont board members, plus three outside
members. Three of the members are from Kingsport, TN; three are from Johnson City, TN; one
is from Marion, VA; one is from Bristol, VA; one is from Elizabethton, TN; one is from Big Stone
Gap, VA; and one is from Greeneville, TN. Board committees are similarly composed. The
majority of the executive team lives outside of Johnson City. The lead independent director of
the board was formerly a member of the Wellmont board. This is hardly a Mountain States
takeover.

In Summary
Overall, your many sweeping generalizations are without context, without evidence, or both. Southwest
Virginia is not Boston where you had the privilege to train, and Ballad Health’s rural hospitals, physician
practices, and skilled nursing facilities are not boutique clinics that are allowed to pick and choose their
patients with the means to pay in cash.

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If you do oppose what we are attempting to do, what would your alternative be? Had Wellmont sold
their hospitals to an outside hospital system, Mountain States would have followed suit. A cross-market
merger such as this would have undoubtedly increased prices, nearly 1,000 back-office jobs would have
been eliminated, and more rural hospitals in your region would have closed. This is not merely
conjecture; it was already happening. Lee County was only the start.

Had the merger not occurred, at least three additional hospitals in Southwest Virginia would have likely
closed. In fact, at least one outside suitor of Wellmont during their strategic options process insisted
Wellmont’ s money-losing rural hospitals would have to be closed as a condition of the merger. To this
point, after many months of analysis of the data, Commissioner Marissa Levine, MD, of the Virginia
Department of Health, presented her findings of facts approving the merger. In her report dated October
30, 2017, she stated, among other things:

“At a time when the continued operation of many rural facilities is at risk, the Applicants have
made commitments to keep all Virginia hospitals open as clinical and health care institutions
for at least five years. This is a significant commitment to preserving access to care and a
benefit to the people of southwest Virginia that will result from the cooperative agreement.”

Ballad Health has no fear of hard questions or criticism from the public or public officials. We do
however, share with the rest of the citizenry an expectation that public criticism – especially from a
candidate for public office – is well researched, truthful, and contributes meaningfully to the public
debate. Again, our offer stands to meet and discuss healthcare in the region and Ballad Health’s efforts
to improve it.

Sincerely,

Anthony Keck
Executive Vice President System Innovation and Chief Population Health Officer
Ballad Health

cc: Rob Walters, Managing Editor, Bristol Herald Courier

William C. Wampler, III
Ballad Health Community Hospital Boards of Southwest Virginia

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