2020 Department Annual Report Covering Fiscal Year July 1 .

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2020 Department Annual ReportCovering Fiscal Year July 1, 2018-June 30, 2019Tennessee Department of Health April 6, 2020

Executive Summary . 3Introduction and Background. 4The COPA . 5The Department Annual Report . 6Annual Review . 7Findings from Reports . 10The COPA Compliance Office Annual Report .10Ballad’s Periodic Reports .11The Local Advisory Council Annual Report .17The COPA Monitor Annual Report.17The Population Health Report .17The Access to Health Services Report .19The Other (Quality) Report. .22Response to Local Advisory Council (LAC) recommendations. 27Response to the COPA Monitor recommendations . 30Department’s Recommendations to Ballad. 31Department’s Recommendations to the COPA Monitor . 32Conclusion . 33Prior Findings .33Current (Year 1) Findings .33Future Findings .342

Executive SummaryIn 2018 the two largest health systems in Northeast Tennessee, Wellmont Health System andMountain States Health Alliance, were issued a Certificate of Public Advantage (COPA) andallowed to merge under the name, Ballad Health. The Tennessee Department of Health (TDH)required the new health system to reinvest expected savings from the merger in ways thatwould substantially benefit residents living in the system’s geographic service area.The state required the formerly competing systems to agree to a number of terms andconditions that were set out in the Terms of Certification (TOC), a document governing theCOPA. Importantly, the TOC stated that the system would be Actively Supervised by the stateand subject to an annual review.This Department Annual Report is on TDH’s Annual Review of the Ballad Health COPA andincludes determinations of compliance, the Sub-Index Scores, the Final Score, the Pass/FailGrade, and other elements relevant to the Active Supervision of the COPA.TDH identified several successes in Ballad Health’s Fiscal Year 2019 that were attributable to themerger. Chief among them was that all of the system’s 21 hospitals, including its manyvulnerable rural hospitals, remained open.TDH also identified opportunities upon which the success of the COPA depends. These includepublic communication, realignment of evaluation metrics, and the demographics in the region.TDH confirmed that all of the Ballad Health periodic reports were submitted in compliance withthe TOC. However, TDH and VDH are in discussions with Ballad Health to revise the requiredcontent of Ballad’s periodic reports to improve the usefulness of the information provided.Highlights from the Ballad Health Fiscal Year 2019 Annual Report, include: Ballad Health improved access to healthcare by opening a rural hospital in UnicoiCounty, Tennessee, in Fiscal Year 2019 and investing in an additional rural hospital, inLee County, Virginia, scheduled to open in Fiscal Year 2021. Ballad Health leading the establishment of an Accountable Care Community thatconsists of over 250 diverse organizations that, through a collective impact process,have decided to improve community health by creating more safe, stable, and nurturingenvironments for children and supporting families in the region. Ballad Health’s quality performance, by comparing the raw numbers from Ballad’s FiscalYear 2019 against their established baselines, appeared to have improved for 11 of the16 measures, while scores slipped for two of the three patient satisfaction measures.3

The State’s Active Supervision structure includes the critical investigative work of the COPAMonitor and the public input facilitation of the COPA Local Advisory Council. Findings fromthese bodies related to Fiscal Year 2019 are shared in the COPA Monitor Annual Report andLocal Advisory Council Annual Report, respectively.As part of its Active Supervision work, TDH published three Sub-Index reports with recent dataon population health measures, access to health services measures, and other (quality)measures related to improvement and performance expectations for the health system, forpatients, and for residents in the region. In accordance with the procedures and requirementsof the TOC, data in the three Sub-Index reports and the Ballad Heath Annual Report are used todetermine if Public Advantage is demonstrated in each fiscal year. The data were assignedweights and calculated into Sub-Index Scores for Fiscal Year 2019.TDH’s calculation of the Sub-Index and Final Score agree with the score recommendations inthe COPA Monitor’s Annual Report. They are:Economic Sub-Index : PassFINAL SCORE : 92Pursuant to the Terms of Certification, with a Passing score in the Economic Sub-Index and aFinal Score of 92, TDH determined that the Ballad Health COPA continues to demonstrate aPublic Advantage.Note: This report covers the time period from July 1, 2018 to June 30, 2019; consequently, the reportdoes not include the coronavirus pandemic and its impact on Ballad Health. Readers are advised tokeep that in mind when reading this report.4

Introduction and BackgroundThe COPAA Certificate of Public Advantage (COPA) is the written approval by the TennesseeDepartment of Health (TDH) that governs a Cooperative Agreement (including a merger) amongtwo or more hospitals. A COPA provides state action immunity to the hospitals from state andfederal antitrust laws by replacing competition with state regulation and ActiveSupervision.TDH has the authority to issue a COPA if applicants pursuing a COPA demonstrate that thelikely benefits of the proposed Cooperative Agreement outweigh the likely disadvantagesthat would result from the loss of competition. The ability to grant a COPA is authorized byTennessee’s Hospital Cooperation Act of 1993, amended in 2015. Permanent Rules 1200-38-01implement T.C.A. § 68-11-1301 – 68-11-1309.In February of 2016, the two largest health systems in Northeast Tennessee, Wellmont HealthSystem and Mountain States Health Alliance, submitted an application for a COPA. Theapplicants explained that if allowed to merge, they would realize savings by reducingduplication and improving efficiencies that they would reinvest in ways that wouldsubstantially benefit those residing in their Geographic Service Area (GSA).Their combined GSA includes 10 counties in Northeast Tennessee and 11 counties in SouthwestVirginia. This part of the Appalachian Region is largely rural, and has a number of health,economic, and other challenging factors that when combined present a unique and difficultenvironment for improving the quality of and access to health care and health outcomes.On January 31, 2018, in coordination with the Tennessee Attorney General’s Office, TDH issueda COPA to Mountain States Health Alliance and Wellmont Health System, allowing them tomerge under the name Ballad Health. TDH and the AG’s Office developed the Terms ofCertification (TOC) to govern the COPA. The TOC lays out Ballad’s obligations andresponsibilities and the regulatory role of the State. This document details the conditionsrequired by TDH for Ballad to demonstrate ongoing public advantage.Within the TOC is a description of the Index and scoring system that will be used to trackand evaluate the demonstration of ongoing public advantage along four categories (subindices):5

Access to Health Services Population Health Improvement Economics Other (primarily quality of care)Via the COPA Index, TDH will track the progress under the Cooperative Agreement and annuallydetermine if a public advantage is maintained for the residents of the GSA. Based on the size ofthe region, the size of the population impacted, and the involvement of two states, this COPA isan unprecedented process.The Department Annual ReportPursuant to the TOC, TDH is required to prepare an Annual Report that incorporates findingsfrom (i) Ballad Health’s Periodic Reports, (ii) the COPA Compliance Office Annual Report, (iii) theLocal Advisory Council Annual Report, (iv) the COPA Monitor Annual Report, (v) the HealthcareAccess Report, and (vi) the Population Health Report. The Department Annual Report must alsoinclude determinations of compliance, the Index Scores, the Final Score, the Pass/Fail Grade,and trends relevant to the Active Supervision of the COPA and continued Public Advantage foreach Fiscal Year when this information is available.The 2020 Department Annual Report is the last in a series of Annual Reports required by theTOC this Fiscal Year. The Fiscal Year 2019 Ballad Health Annual Report and COPA ComplianceOffice Annual Report were submitted roughly 120 days after the end of Ballad’s Fiscal year. TheLocal Advisory Council (LAC) held a Public Hearing on January 7, 2020 to allow residents torespond to the Ballad Health Annual Report and subsequently published the Local AdvisoryCouncil Annual Report on public feedback. The LAC’s report submitted February 6, 2020included recommendations to the COPA Monitor and to TDH. The COPA Monitor Annual Reportwas provided to TDH on March 6, 2020, in which the COPA Monitor reported on Ballad’sperformance against the Index and provided recommendations to TDH as well as to BalladHealth.6

Annual ReviewSection 7.02 of the TOC reads:Pursuant to Tenn. Code Ann. §68-11-1303(g), the Department shall review, on at least anannual basis, the COPA to determine Public Advantage (the “Annual Review”). TheDepartment shall review whether Public Advantage is demonstrated or not for each FiscalYear during the COPA Term, in accordance with the procedures and requirements of theCOPA Act and (the TOC). This Annual Review shall include, without limitation, thefollowing: (i) the determination of the Final Score and Pass/Fail Grade, (ii) the COPAParties’ degree of compliance with the Terms and Conditions, and any and all COPAModifications and Corrective Actions occurring prior to such review, and (iii) trends of(Ballad Health’s) performance hereunder since the Issue Date and other factors (whichmay or may be reflected in the Index) relevant to the Department’s determination of thelikely benefits and disadvantages of the Affiliation which, as of the time of suchdetermination, can reasonably be expected if the Affiliation is continued.As in the first Department Annual Report, TDH will include as a part of its review comments onthings that are working well, challenges, and concerns that either surfaced or persisted in thepast year.Things that are working well.TDH has identified the following COPA-related successes of the past year: Hospitals that were under threat of closure remain open. Ballad Health submitted each of the required periodic reports and three-year plans incompliance with the TOC. Ballad Health promptly provided additional data and information on qualityperformance upon request. Ballad Health promptly provided additional data and information on the AccountableCare Community upon request. The COPA Compliance Office responds quickly and thoroughly to inquiries from TDH. Ballad’s Health’s executive staff meets frequently with the COPA Monitor and providesinformation upon request.7

Ballad Health participated meaningfully in quarterly meetings to discuss progress madein implementing each of the system’s following three-year plans: Population Health Plan,Children’s Health Plan, Behavioral Health Plan, Rural Health Plan, Health InformationExchange Plan, and the Health Research and Graduate Medical Education Plan. Ballad Health’s staff, along with key members of the TDH and Virginia Department ofHealth (VDH) participated in a robust review of each of the Sub-Index measures foravailability, validity, and reliability as part of a metrics workgroup. Agreeable solutionswere found on the most concerning measures for each Sub-Index. The workgroup alsodeveloped a proposed set of metrics for tracking progress on each of the system’s threeyear plans. TDH remains impressed by the size and range of stakeholders participating in theAccountable Care Community (ACC), which Ballad Health played a lead role inestablishing in the region. TDH is optimistic about the ACC’s new Striving TowardResilience and Opportunity for the Next Generation (STRONG) Children and Familiesmodel for change and is interested in discussing how to support Ballad’s alignment withthe ACC’s STRONG approach. Ballad Health’s quality performance, by comparing the raw numbers from Ballad’s FiscalYear 2019 against their established baselines, improved for 11 of the 16 measures.OpportunitiesTDH has identified the following items as COPA-related opportunities: Communication. TDH staff, the Local Advisory Council, and Ballad Health, all haveopportunities for better communication with the public. Terms of Certification. TDH and the Attorney General’s Office have identifiedopportunities for clarification and refinements to the Terms of Certification, mostnotably to Addendum I, which they plan to discuss with Ballad. Employing physicians. In section 5.05(e) of the TOC, a 35% cap on employingphysicians in any specialty at any of Ballad’s three “non-rural” facilities was established.TDH and the COPA Monitor are discussing ways to make this cap more meaningful. Data difficulties. Multiple challenges related to data and evaluation were encounteredover the past year, some of which have been resolved or are in the process of beingresolved such as:oAligning Tennessee’s Index measures (active supervision evaluation metrics) withthe evaluation measures used in Virginia (partially resolved).8

oExploring ways to ensure a clear and objective evaluation system is maintained,while allowing some ability to account for unforeseen policy, economic, andenvironmental changes that might also impact an evaluation metric (ongoing).oIdentifying scientific approaches to determining if improvement is achieved ineach Sub-Index and monitoring measure (resolved).oEnsuring the ability to independently verify the results for measures where thehealth system is the data source (ongoing).Economic development. The ability of Ballad Health to maintain quality of care acrossits facilities and access to care across the geographic service area will becomeincreasingly challenging in a region with a declining birth rate and an aging population.Concerns specific to BalladTDH has the following concerns regarding Ballad Health’s initial experience operating under aCOPA which include: Ballad Health’s ability to recruit the number of children’s health specialists listed inBallad Health’s Children’s Health Plan. Due to the current national physician shortage,particular recruitment challenges that traditionally face rural hospitals, and decliningbirth rates in the system’s service area, TDH believes Ballad Health will continue to havedifficulty attracting and retaining the specialists it lists. TDH would like Ballad Health tosubmit a revised Children’s Health Plan with strategies that do not rely on recruitment ofpediatric specialists or the attainment of a Comprehensive Regional Pediatric Centercertification.Resolved instances of potential non-complianceThe COPA Monitor addresses potential COPA and TOC violations in his COPA Monitor AnnualReport. TDH is not aware of any additional potential or confirmed non-compliance eventsunder the Terms of Certification.9

Findings from ReportsThe COPA Compliance Office Annual ReportThe COPA Compliance Office Annual Report is available hereFindings: The COPA Compliance Office Annual Report was filed in compliance with the Terms ofCertification and included required information. A chart summarizing the complaints received by the COPA Compliance Officethroughout the year by type was provided. (Details of each complaint were listed in theCOPA Compliance Office Quarterly Reports.) TDH engaged in lengthy follow up discussions with Ballad Health regarding theExemption for Payment Indices on Ambulatory Surgery Centers/Ambulatory SurgeryTreatment Centers (ASC/ASTC) due to the sale of interest in the ASC/ASTC that reducethe ownership interest held by Ballad Health such that the system is no longer amajority owner; TDH initiated discussions that ae ongoing with Ballad Health regarding the followingRequests for Modifications/Extensions listed in the report: oProposed Base Charity Care provisions in the Terms of Certification; andoRequest for changes to Population Health Measures.The Report on Potential Violations of the TOC was complete for Fiscal Year 2019. Allissues have been resolved except for the following:oOut of concern that collection efforts for services to patients insured by an outof-network Payor had not been compliant with Addendum 1 of the TOC,collection efforts for these patients were suspended. TDH, in coordination withthe Office of the Attorney General and the COPA Monitor, is consideringclarifying and revising formulas that apply to out-of-network payors andpatients, which would impact the collection practices of Ballad Health withaffected patients.10

oSpending commitment made by Ballad Health for Fiscal Year 2019 are underreview by the COPA Monitor for their compliance with the TOC. The COPA Compliance Department projected spending 2.32 million in Fiscal Year 2020on COPA Compliance, which was far below the Fiscal Year 2019 projection of 4.77million. (A revised projection of 4.2 M was later communicated to TDH.)Ballad’s Periodic ReportsBallad Health Quarterly Reports are available at the following links: Fiscal Year 2019 Q1 Report (reporting period: July 1, 2018-September 30, 2018) can beread here. Fiscal Year 2019 Q2 Report (reporting period: October 1, 2018-December 31, 2018) canbe read here. Fiscal Year 2019 Q3 Report (reporting period: January 2019-March 2019) can be readhere. Fiscal Year 2019 Q4 Report (reporting period: April 2018-June 2018) can be read here.Findings: Ballad Health’s four quarterly reports were submitted in compliance with the Terms ofCertification and included all required information.The Ballad Health Annual Report is available here.Findings: The 278 page Ballad

TDH also identified opportunities upon which the success of the COPA depends. These include public communication, realignment of evaluation metrics, and the demographics in the region. TDH confirmed that all of the Ballad Health pe

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