Now that it has settled into a monopoly over Central Appalachia’s health care, the Ballad Health system is stirring new controversy with a move intended to conserve money:  consolidating intensive care facilities.

Last year, they announced plans to merge their two Level 1 trauma facilities and their two neonatal intensive care units (NICUs) into just one of each facility for the whole region.

Prior to the merger, Level 1 trauma care (the highest level of such care) was provided at both Holston Valley Medical Center in Kingsport, TN and Johnson City Medical Center, twenty miles away in Johnson City, TN. Trauma emergency services at the Kingsport facility were recently downgraded to Level 3, while being maintained as Level 1 in Johnson City.  At the same time, Ballad announced that the NICU in Kingsport would close, moving all  neonatal intensive care services to Johnson City.

To say that these changes have been controversial would be a gross understatement.  For months, advocates have argued that consolidating these services will result in unnecessary deaths, increased morbidity, and unacceptable inconvenience for family and loved ones living in more remote areas of the region. Ballad officials have claimed that the reduction of duplicate services is necessary to maintain quality of care and reduce expenses, and that doing so will not have a negative impact on health care in the region.  The truth almost certainly lies somewhere between the two positions, but is not easily discerned. And I don’t consider myself qualified to provide a definitive answer.

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Beyond the immediate question of the impacts these specific consolidations will have, the closure of these Appalachian intensive care units is one example of health care rationing as it exists in the U.S. 

Health care rationing is often thought of as something that occurs in other countries, something to be avoided at all costs here in the U.S.  The reality, however, is that we do ration health care in this country. We do so primarily by limiting access based on a patient’s ability to pay for care.

For 87 million Americans who are either uninsured or underinsured, access to health care is significantly impacted by the cost of care. Emergency departments will usually provide care to individuals with true emergencies regardless of their ability to pay. However, those without adequate insurance or other financial resources have significantly limited options for their day-to-day health care needs, including preventive services, management of chronic medical conditions, and care of non life-threatening acute problems. 

For those with “adequate” insurance, care is still rationed by what their coverage will pay for. Insurance companies ration care through deductibles and copays (discouraging use of medical services and prescription medications), preferred provider panels (limiting which providers will be paid for), and prior approvals (limiting what diagnostic and therapeutic interventions will be paid for).  While these may be useful as cost-saving measures, they are, nonetheless, forms of rationing.

While rationing on an individual level may seem and often is capricious and harmful, on a societal level it is necessary. Health care costs in the U.S. are already exorbitant. Without some control over how much is spent, and on whom, costs would be even more unaffordable.  It would be wonderful to have Level 1 trauma services in every small city across the country, especially those in rural America; lives would doubtlessly be saved and families spared great inconvenience. But the reality is that they are tremendously expensive to maintain, and we simply can’t afford to have that many trauma centers.  

Prior to the consolidation of Ballad’s Level 1 trauma facilities, there were six Level 1 trauma centers in Tennessee. Four of these were spread rather evenly across the state from Memphis to Knoxville, a distance of almost 400 miles, while our two were located only 25 miles apart about 100 miles from the closest in Tennessee and 170 miles from the closest in Virginia.

Meanwhile, there is no Level 1 trauma facility between Omaha, Nebraska and Seattle, Washington.  More than 5 million people live in the mostly rural states of Idaho, Montana, Wyoming, North Dakota and South Dakota, with more than 450,000 square miles and not a single Level 1 trauma center among them. In comparison, the catchment population for Ballad Health is estimated at about 1.2 million people spread over about 11,000 square miles.  When viewed from that perspective, perhaps our region doesn’t really need two Level 1 trauma centers. Maintaining the staff and facilities for those services is expensive, so consolidation makes sense from an economic standpoint. In addition, evidence suggests (though not conclusively) that facilities managing larger volumes of critical care services may provide a higher quality of care.  It doesn’t make sense to have duplicate services simply for convenience. As harsh as it may seem, with limited health care resources, such decisions should be made on the basis of cost-benefit analyses and economic factors.

The fundamental question is how such decisions should be made.  Who should determine how to allocate limited resources that are deemed to be essential? Health care providers, health systems, and for-profit insurance and pharmaceutical corporations should not be in the position of making those decisions. Clearly there needs to be independent oversight. In the case of Ballad, this oversight is now in the hands of two different states. There are very real concerns as to how effectively Tennessee and Virginia will be able to monitor the results of the merger and hold Ballad accountable. Federal Trade Commission staff have questioned their ability to do so.  North Carolina’s experience with Mission Health in western North Carolina and their COPA suggests that the critics may be correct.

Ultimately, there needs to be centralized oversight of all large health care players to assure that quality, cost-effective health care is available to all Americans.  Representative Pramila Jayapal’s Medicare for All Act of 2019 (H.R. 1384, with 120 co-sponsors) would do just that.  Under such a system, institutional providers such as hospitals, skilled nursing facilities, and home health agencies would be paid lump sum global operating budgets on a quarterly basis. Regional directors would have the responsibility of conducting regular health care needs assessments, establishing quality assurance mechanisms, and recommending changes in reimbursement to providers based on the volume and quality of care provided. 

There is no question that with such a federal program, health systems would be much more accountable than they are currently, and when health care rationing occurs, it is in the best interest of all Americans.