JOHNSON CITY — Ballad Health last week announced quality, investment and financial results from its first full fiscal year of operation as a combined system.
“Despite the national challenges faced by hospitals, including nursing shortages and the phenomenon of ‘ER boarding’ of patients in need of behavioral health services, Ballad Health’s operational performance has been demonstrably exceptional, as evidenced by objective performance measures,” said Alan Levine, chairman and chief executive officer of Ballad Health. “This is attributable to the incredible work of our doctors, nurses and support team members who focus every day on better quality and lower cost.
“The improvement in our financial and quality performance has led to lower costs, which translates into savings for the employers in our region, a goal we remain committed to. This improvement has also allowed us to make additional investments in nursing resources, which we hope will help alleviate the stress of the nursing shortage on our staff.”
Nursing shortage an imminent and growing issue for the nationAccording to the United States government, there is a projected national shortfall of 800,000 nurses by the year 2020. The U.S. Health Resources and Services Administration projects that Tennessee will only be able to meet half of the demand for registered nurses by next year.
The National Rural Health Association has called the nursing shortage “a plague throughout the United States, and rural communities are hit harder than their urban counterparts.”
In a comprehensive report released by the NSI Nursing Solutions, Inc., titled “2019 National Health Care Retention and RN Staffing Report,” the shortage of registered nurses will reach 1.13 million by 2024. The report cites a “rising turnover and a retirement wave about to break,” with nursing turnover about to “set a new high-water mark for the decade.” Finally, the report states, “half of hospitals would like to decrease their reliance on supplemental staffing.”
Data released from the National Council of State Boards of Nursing provides a sobering reminder of the looming challenges for meeting nursing workforce demands. According to the data, the average age of registered nurses in 2017 was 51, and half of all nurses practicing today are older than 50. This data supports the finding by the NSI Nursing Solutions survey that indicated a breaking retirement wave, and it might also help explain why national nursing turnover is increasing to its highest levels in recent history.
“Ballad Health has not been immune to the effects of the national nursing shortage, and no doubt this shortage is being felt throughout our system, both by our team members and by our patients,” said Lisa Smithgall, Ballad Health’s chief nursing executive. “We have taken, and continue to take, steps to alleviate this problem – a problem not created by Ballad Health, but certainly one we must deal with.”
Certain steps have been taken by Ballad Health to alleviate this issue, including:
• A $10 million annual investment into increasing direct patient care nursing wages, affecting nearly one-third of Ballad Health’s workforce. To put this investment into context, Ballad Health’s entire operating income in fiscal year 2018 was $9.9 million. This investment represents 100% of Ballad Health’s operating income from the last fiscal year.
• Ballad Health has organized a nursing leadership council and nursing advisory committee to advise leadership on steps and initiatives that can be taken to help improve nursing retention, satisfaction and recruitment. Many of the steps being taken by Ballad Health are the results of this feedback.
• Based on feedback from nursing staff, Ballad Health has implemented an updated and more robust clinical nursing ladder program. This program is a best-practice model designed to provide less experienced nurses with mentorship and growth opportunity to expand their skills. As they achieve milestones, they can earn increased pay and responsibility.
• Like most health systems, Ballad Health seeks to reduce the number of contract, or traveler, nurses. This is intended to help improve quality of care and nursing satisfaction. Ballad Health has been successful reducing the use of temporary traveler nurses by 50% over the last year, while at the same time continuing to utilize them in areas of significant need or during times of peak volumes.
• Ballad Health has worked with physicians and payers to reduce the number of lower acuity admissions. As outlined in this release, Ballad Health has reduced the number of low-acuity admissions by more than 5,000 this year. By avoiding these admissions, Ballad Health has been successful in reducing demand for nurses.
• Ballad Health has guidelines for nurse-to-patient ratios that are appropriate and within the standards of the industry. In each hospital, nurse leaders determine during each shift the acuity and volumes of patients and take into consideration the available staffing based on volume, which fluctuates throughout the day. At times, when volumes expand, if there is not enough staff to safely manage the volume fluctuation, the hospital may go on diversion for that particular service, or patients who need a certain type of bed might be required to wait in the emergency department until such beds are available. This is a deliberate strategy to ensure patient safety and protect nurses from being asked to routinely handle too many patients – something that can lead to patient harm and nurse burnout. The decision to go on diversion or hold patients in the ER is only made once it is determined the admission of additional patients would compromise patient safety. During these circumstances, Ballad Health attempts to utilize supplemental nurse staffing to create additional capacity. While this can be inconvenient for patients and their families, patient safety is always Ballad Health’s paramount concern. The health system recognizes its nurses often care for a high volume of patients, and it continues to work with its colleagues in the healthcare industry to seek solutions to the shortages, which have disproportionally affected rural and non-urban communities across America.
• As it relates to patient wait times in the emergency department, a phemonenon that can occur due to fluctuations in patient volume, Ballad Health is also dealing with another national problem associated with the “boarding” or “holding” of patients with mental illness who need behavioral treatment placement. On many days, Ballad Health is holding more than 60 patients in emergency departments, while resources are identified in the community to provide assistance. These “hold” patients require staffing, which further strains the limited resources available. The patients do not have medical conditions, but for a variety of reasons, they cannot be released. Ballad Health’s new Behavioral Services Division is developing alternative solutions to assist these individuals, which will hopefully assist in diverting them from its emergency departments. This phenomenon is not unique to Ballad Health and is experienced nationally. It results in increased wait times in the emergency department and possible delays in getting admitted patients to hospital beds, as resources have to be diverted to care for these individuals.
• Ballad Health has endeavored to eliminate unnecessarily duplicative services, as duplication spreads out nursing resources such that optimal staffing cannot be achieved. For instance, if there are two emergency departments located within four miles of each other in a community where the hospitals are running at or below 30% capacity, then it requires more nurses to staff both emergency departments and hospitals. This misapplication of resources leads to suboptimal staffing and potentially more shortages.
• Better integration in staffing models has led to more patients being treated in lower-cost settings in their home communities. For instance, in Wise County, Virginia, the cross-coverage of physicians made possible by the merger has led to more stable staffing and an 18% increase in surgical volume. Prior to the merger, surgical cases were often transferred to Kingsport due to inconsistent staffing coverage and the inability to refer patients to a competing hospital in the same county.
• Prior to the merger that created Ballad Health, it was estimated as many as 1,000 jobs would be eliminated had both legacy health systems been acquired by systems based elsewhere. The administrative consolidation of Wellmont Health System and Mountain States Health Alliance resulted in the elimination of approximately 200 administrative positions. According to the state of Tennessee, fewer job losses resulted from the merger than what was originally anticipated. This is a clear benefit of the merger as opposed to the alternative.
Speaking to Ballad Health’s results for the year, on behalf of the independent members of the board of directors, lead independent director David Lester said, “The board of directors of Ballad Health is composed of people who live here, employ people here and whose families rely on the services here. We are pleased with these operating results, which demonstrate that, against serious headwinds for all hospitals in the nation, Ballad Health is taking the right steps to ensure patient safety, demonstrably higher quality and stable financial performance – all of which are necessary and important.”
Quality improvement resultsDriven 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 on Feb. 1, 2018.
Recently, US News reported that all four of Ballad Health’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% of all hospitals had any top-performing programs, according to US News. In Tennessee, all three of Ballad Health’s flagship hospitals were among the top-performing hospitals, while in Virginia, Johnston Memorial was among the top performers.
Additionally, in the US News rankings, Bristol Regional and Holston Valley moved up in overall rankings from No. 10 in Tennessee last year to No. 7 this year. And recently, Forbes Magazine named Johnson City Medical Center as one of the best employers in Tennessee, among all employers.
In partnership with physicians and clinical staff, Ballad Health has seen a focused effort on quality improvement significantly benefit patients. Specific examples include:
• Zero infections for abdominal hysterectomy cases across the system
• 47% reduction in pressure injury rate
• 42% reduction in clostridium difficile infections
• 39% reduction in iatrogenic pneumothorax rate
• 13% reduction in central line blood stream infections
Investments by Ballad Health also are beginning to generate benefits for the region. Recently, Ballad Health announced the opening of the region’s newest assisted living facility in partnership with Signature HealthCARE, a facility focused on the emerging needs of the elderly. 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 Quillen College of Medicine. Ballad Health also announced plans to open a new rural hospital in Lee County, Virginia – an effort not required by the Certificate of Public Advantage (COPA) or Cooperative Agreement, but supported by the board of directors to improve access.
In the past year, Ballad Health also 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 $45 million. These savings have not only benefitted federal taxpayers; evidence shows area employers are benefitting from partnering with Ballad Health.
Recently, the mayor of Washington County, Tennessee, released data demonstrating that county employee healthcare costs have decreased due to efforts by Ballad Health to partner with the county and BlueCross BlueShield of Tennessee – resulting in a 10% decrease in healthcare costs and premiums for employees.
“Lower cost and higher quality go hand in hand,” said Dr. Amit Vashist, chief clinical officer of Ballad Health. “Not only are we demonstrating that reducing lower acuity admissions is beneficial to patients and the payers, but we are also seeing improvement in measures of quality within our hospitals. We strive to be a zero-harm, top-decile institution, and so far, the work of our unique clinical council in partnership with our administrative leadership is showing promise.”
Ballad Health was selected by the High Value-Care Collaborative to participate with leading health systems to adopt strategies that will reduce unnecessary costs and deliver evidence-based care that’s been demonstrated to reduce the burden on patients. The High Value-Care Collaborative is a joint project between the American Hospital Association, the American Board of Internal Medicine Foundation’s Choosing Wisely Campaign and the Costs of Care organization.
“Our priority is exceptional patient care,” said Dr. Clay Runnels, chief physician executive of Ballad Health. “Our physicians stand alongside leadership as we seek to become one of America’s leading health systems. The recent investment into physician leadership is demonstrative of Ballad Health’s determination to ensure this is a place where physicians want to practice.”
Investment into new physicians and advanced practice providers for regionSince the closing of the merger, Ballad Health has recruited more than 150 new physicians and advanced practice providers to serve the region. Successes include the recruitment of cardiology in rural Wytheville and Norton, Virginia; nephrology in Abingdon, Virginia; and urology in Kingsport. Throughout the region, Ballad Health has also recruited neurology, orthopedics, pain management, hospitalists, psychiatry and other needed specialties.
Financial strength“Ballad Health has so far been successful providing lower overall costs to consumers while also improving its own financial performance, proving that better quality should mean lower costs,” Levine said. “Our improved financial performance is positive proof that by reducing lower acuity admissions and working with our payers across Medicare, Medicaid and commercial lines of services, we can reduce the cost of care for employers and consumers. These opportunities will expand as payment models move further toward increased sharing of risk between the payers and Ballad Health. By focusing on reducing unnecessary duplication in cost, we can be stronger financially as we continue to see a decline in inpatient utilization.”
Financial results for the year include:• For the year ending June 30, 2019, operating cash flow improved to $228.1 million from $197.6 million in the prior year, a 15.4% improvement.
• Total cash flow (EBITDA) improved to $254.6 million versus $199.6 million in the same 12-month period prior year, a 27.5% increase.
• EBITDA margin improved from 9.9% in the prior 12-month period to 12.5% in the current 12-month period.
• Revenue for the year grew 1.3%, while expenses remained flat, leading to an improvement in the operating margin to 1.7% from 0.5% in the prior year.
• Operating income for the year improved to $36.5 million from $9.9 million in the same period prior year.
Ballad Health’s improved financial performance for the year follows dedicated expense management, improvements in productivity, reduced reliance on temporary/contract labor and focused supply cost management.
Ballad Health’s investment into the region’s labor force is extremely powerful, with Ballad Health spending $1.043 billion on salaries, wages and benefits for the year.
These improvements are in spite of challenges, both reflective of what all providers are facing and some that are unique to Ballad Health and the region.
• Ballad Health continues to see a trend of declining volumes in certain services, with adjusted discharges for the 12-month period declining 0.8% to 247,013. Inpatient surgeries declined 2.7% to 20,948. Outpatient surgeries, including ambulatory surgical cases, declined 1.4% to 51,677. ER visits declined 3.8% to 432,394 visits.
• Ballad Health continues to experience declining inpatient and hospital utilization rates, a phenomenon experienced throughout rural America. The decline in hospital admissions in Ballad Health’s service area is driven in part by the efforts of Ballad Health and area physicians to utilize lower-cost alternatives to hospital stays as appropriate. This successful reduction, when combined with low population growth, reduces the overall volumes in the hospital setting. This year, Ballad Health had 5,085 fewer admissions, with approximately 4,290 of those admissions being lower acuity medical admissions.
• While admissions are declining, the overall patient mix shifted to higher-acuity patients (patients who are sicker), with overall patient acuity increasing by 20 basis points.
“Ballad Health is facing a rapidly changing landscape where our financial success is no longer judged solely by volume, but increasingly, how we care for fewer people more efficiently, effectively and with better outcomes,” Levine said. “Many of the quality metrics that we’ve seen improve have led to lower costs. Lower lengths of stay, reduced rates of hospital-acquired conditions, reduced readmissions and better integration with physicians have helped reduce the cost of care and helped Ballad Health achieve success with the new value-based purchasing environment.”
Reinvestment of capital throughout the regionWhile Ballad Health has focused on improved financial performance, it has also continued to invest nearly $200 million in capital for new equipment, diagnostic technology, building improvements, information technology intrastructure and a common electronic health record. Just a few examples of capital spending in the year included:
• Electrophysiology lab upgrades, echocardiography devices and cardiac ultrasound replacements
• Five new digital mammography systems
• Hospital beds, patient monitors, ventilators and IV pumps
• Hybrid cardiovascular surgical suite
• Internal facility renovations
• Neurospine imaging and navigational diagnostic systems
• New equipment for the opening of a new hospital
• New operating room tables and bariatric surgery equipment replacement MRI, CT and PET scanners
• Resealing and external upgrades to physical plant
• Three-dimensional cardiac wltrasound
• Two new cardiac catheterization labs
• Ultrasound and radiology upgrades