Dr. Teresa Tyson and the Health Wagon team have started to administer COVID-19 vaccines in this part of Appalachia by traveling door-to-door. Here, Tyson prepares to administer a vaccine to Marty Wells at his home in Norton, Virginia. (Photo by Stacy Kranitz/100 Days in Appalachia)

This story was originally published by 100 Days in Appalachia.

When the sun rises over the Cumberland Mountains of southwest Virginia in mid-spring, it’s hard to imagine all’s not well in this world. Saturated in mountain laurel and flowering dogwood, this is picture-postcard central Appalachia.

But for a good many people in these rural, remote counties, each day’s a challenge. All four of the Virginia counties that make up the state’s border with Kentucky and Tennessee are classified as distressed by the Appalachian Regional Commission, meaning they have substantially higher poverty or lower income levels than national averages. The local economy was once driven by coal and tobacco. Both have been in steady decline for more than a decade.

“I love southwest Virginia with all my heart. I will die here,” says Wendy Welch, director of the Graduate Medical Education Consortium and Area Health Education Center of Southwest Virginia, which identifies and addresses health care workforce issues. “But southwest Virginia is not a prize very many people want to fight over.”

Providing health care services here presents enormous challenges. Those four distressed counties – Buchanon, Dickenson, Lee and Wise – all rank near the bottom in the state in health outcomes, including higher instances of asthma, COPD and emphysema.

A coal processing and storage facility in Lee County, Virginia. There has been an unprecedented increase in the number of Appalachian miners diagnosed with progressive massive fibrosis, the most severe form of black lung disease. While coal mining is a declining industry, many cases being diagnosed today date back to work in the 2000s. (Photo by Stacy Kranitz/100 Days in Appalachia)

Though coal industry jobs are few in the area today, coal’s legacy looms large in the health of the community. Pneumoconiosis, or black lung disease, is prevalent. A 2018 study of three clinics in the region found what was believed to be the biggest cluster ever recorded of an advanced stage of the disease: progressive massive fibrosis. Young men still arrive at the Stone Mountain Health Services black lung clinic in Lee County in wheelchairs.

“It makes old men out of young men,” says Teresa Tyson, executive director of the Health Wagon, based in the town of Wise, a legend in this region for its care of the most neglected.

Mounting these challenges today is a relatively new health care provider: Ballad Health. Ballad is the product of a 2018 merger of two hospital systems, Mountain States Health Alliance and Wellmont Health System, and has a monopoly on hospital care in southwest Virginia and northeastern Tennessee.

Mountain States and Wellmont were competitors, an arrangement most health care observers here agree was impractical. Dennis Barry, who monitors the merger that created Ballad for the Southwest Virginia Health Authority, said in March that had the merger not occurred, the two systems likely would have been forced to close facilities, most probably rural hospitals.

But a recurrent concern with any hospital merger or acquisition in a region with both rural and urban populations is that this is exactly what will happen – that hospitals and other health care facilities in rural communities will be shuttered, that the most difficult to serve, those most in need, will be forgotten.

The hospital in Lee County closed in 2013. Ballad renovated and reopened it this month, ending an eight-year period in which residents had to drive to neighboring counties for emergency care. The 10-bed critical access hospital has an emergency room, diagnostic radiology and lab services and telehealth access. (Photo by Stacy Kranitz/100 Days in Appalachia)

In 2013, Lee County lost its hospital, in the town of Pennington Gap; it has now reopened. On July 1, Ballad Health tweeted, “This morning we unveiled the sign on Lee County Community Hospital – America’s newest rural hospital.”

Civic leaders and health care providers agree the reopening of Lee County Community Hospital is a critical step in restoring trust in a community that’s felt abandoned. The previous hospital was owned by Wellmont; its closure took the community by surprise.

“It was very abrupt,” says Greg Edwards, born and raised in Lee County, a lawyer and chair of the council that operates Stone Mountain Health Services. Wellmont had invested in upgrading its emergency room, and, Edwards says, had told the district’s congressman they had no intention of closing. But soon after, “They just took off, shut it down; closed.”

At the time of the 2018 merger, Ballad stated on its website: “By creating Ballad Health, we’ll be able to generate savings and reinvest those savings to preserve access to care in rural areas.”

It’s a daunting task. For eight years, folks in Lee County drove a half hour or more to neighboring Wise County, or beyond, to reach a hospital. They now welcome the return of their own, but are still awaiting further reassurance that Ballad’s decision-makers have their best interests at heart.

An Industry That ‘Chewed Them Up’ Left Distrust in Its Wake

Lee is Virginia’s westernmost county – 70 scenic miles east to west, with limited access. It’s a very long way, literally and figuratively, from Pennington Gap to Richmond, the state capital – in fact, eight other state capitals are closer. Residents of the region are certain this distance has consequences. Take for example the distribution of vaccines in a pandemic. Those vaccines arrived pretty quickly in the northern, relatively affluent counties of the state, the suburbs of Washington, D.C. It took some noisemaking to get them here.

“We’re stuck down here in the far end, where people consider us hillbillies and uneducated,” Edwards says.

“These people have built this country,” says Ross Isaacs, who’s been volunteering as a health care provider with the nonprofit Health Wagon for 22 years. “The roads, the fuel in our houses all come from these people who busted their butts. Then what do we do to say thank you? They’re ignored.”

Trust is a big issue here, Isaacs says. “The owners of the mines kind of chewed them up until there’s nothing left and then they’re let go, and there’s no health insurance or anything long term.”

Merger agreements with the states of Tennessee and Virginia stipulated that Ballad Health must keep all hospitals formerly operated by the two merging health systems open as “health care institutions” for at least five years and that it must maintain essential services in every county.

Enforceable price controls were also put in place, ensuring that the rate of growth in prices for health care services at Ballad facilities would stay lower than the national average. Last year, Ballad announced it would institute an average 17 percent price reduction for all physician practices and urgent care, and it increased its discount for the uninsured to 77 percent.

Ballad also committed to addressing persistent public health concerns. It selected as its primary areas of focus substance misuse, tobacco use, obesity and childhood trauma.

A view from the Powell Valley Overlook in Wise County, Virginia. (Photo by Stacy Kranitz/100 Days in Appalachia)

Tony Keck, Ballad’s vice president for system innovation and chief population health officer, says the previous hospital systems were spending $2 billion a year in the region and “by all demonstrable measures, nobody was getting any healthier.”

The mandate, he says, is to “turn the battleship from being a hospital-based system to being a community health-improvement organization.” That’s not just a promise, Keck says, “we actually had to commit to a $308 million investment in community-health improvement over the next decade,” as part of the merger agreement regulated by the two states.

To address the challenges presented by providing health care in a region roughly the size of New Jersey with considerable health disparities, Ballad has formed an accountable care organization, AnewCare Collaborative. This group of area hospitals and doctors screens Medicare patients for needs related to food, housing, transportation and more, and connects them with resources in their community. It’s the largest of its kind in a rural setting in the country.

East Tennessee State University’s Center for Rural Health Research is working with Ballad on initiatives that include early-childhood interventions, whereby they’ll be following mothers and their children over the next 10 years to monitor outcomes. Ballad is further addressing early-childhood issues with evidence-based community health worker initiatives.

And it recently launched a program to provide residential and outpatient addiction treatment and other behavioral services for pregnant women and mothers of young children.

All of these services are part of the hospital system’s efforts to rebuild trust in the communities it now serves. And as Ballard works to rebuild those bonds, there are community-focused health care providers in southwest Virginia that can serve as models.

Models of Care Based on Intergenerational Bonds

The Health Wagon is the medical home to 5,600 patients in southwest Virginia and neighboring rural counties in Kentucky and Tennessee. It runs three clinics and four mobile units that provide acute care and specialty services, including a new dental unit. Dental is one of the greatest health care needs across rural America.

But Executive Director Teresa Tyson, a native of Wise County and a coal miner’s daughter, says their primary focus is on chronic-disease management. And when emergencies arise, they do whatever’s necessary. In the past months, Health Wagon providers have driven the backroads administering Covid-19 vaccines door to door.

Dr. Teresa Tyson visits Shirley Sparks, 84, at her home in Wise County, Virginia. Shirley, who passed away this summer, lived alone and Tyson liked to stop by and check in on her. (Photo by Stacy Kranitz/100 Days in Appalachia)

The Health Wagon relies on telehealth to reach many of its most remote patients. When the internet’s working, that’s how Joyce Baker communicates with Clinical Director Paula Hill.

Baker, 68, lives in Stinking Branch Holler, in Letcher County, Kentucky, where she was born. She worked in the coal mines for 15 years, much of the time as a control room operator. Baker sometimes has trouble breathing. She was hurt on the job and has had neck and lower-back surgeries. 

Hill asks how she’s doing. “I’m okay, honey,” she replies, “it’s just my back’s hurtin’ so bad.”

In addition to their telehealth visits, Baker messages Hill on Facebook or texts or calls when she needs her. “She’s always available to me.”

Stone Mountain’s black lung clinic is a federally funded facility in St. Charles, Virginia. The clinic provides screening, diagnosis, treatment, pulmonary rehabilitation and benefits counseling for patients suffering from black lung. (Photo by Stacy Kranitz/100 Days in Appalachia)

Likewise at Stone Mountain Health Services’s Black Lung Program, the children of coal miners now treat patients who suffer from conditions as a result of working in the industry. Jody Willis, a family nurse practitioner and medical provider for Stone Mountain, grew up in Lee County; her father was a coal miner

“They’ve worked all of these tremendous amounts of hours to get to the point that they can enjoy some of their hobbies, enjoy their grandkids,” Willis says of the miners in her care, “and now they just don’t have the physical capacity to do what they wanted to do.”

Alan Morgan, CEO of the National Rural Health Association, says it’s been borne out time and again that the most essential element of a successful relationship between a community and its health system is a deep understanding of the community and its needs. These community-based providers in southwest Virginia are exemplars of such partnerships.

Better Equipped? Covid Tested the Large, Rural System of Care

Any conversation about health care must be put in the context of the pandemic. Though many in rural communities initially believed the coronavirus would largely be an urban concern, it ultimately overwhelmed them. By September, the death rate in rural America had surpassed that of urban centers.

Kathie Kegley, who lives in Wise, was a nurse in a Covid-19 ward in Ballad’s Holston Valley Medical Center in Kingsport, Tennessee. An aunt and an uncle died 16 days apart in her unit. Friends and friends’ family members also passed away there.

“I’ve seen some amazing nurses and doctors that fought so hard to save these people,” Kegley says. “I put more people in body bags this past year than I have my whole career.”

Downtown St. Charles, Virginia. (Photo by Stacy Kranitz/100 Days in Appalachia)

The financial strain that also came with the pandemic only intensified the challenges rural hospitals were already facing. The University of North Carolina’s Cecil G. Sheps Center for Health Services Research documents 138 rural hospital closures since 2010. A study released in spring of 2020 found that one in five rural hospitals were at risk of closure due to financial stress. The merger of two hospital systems to create the larger Ballad Health may have been a benefit for these isolated communities.

“I’ll be honest,” Kegley says of the Ballad merger, “at first, I did not like it,” didn’t like the idea of a monopoly. But she believes Ballad “really stepped it up during the pandemic,” with protective equipment, additional pay and behavioral health support for staff.

She, like many others in the region, believes that, as a large entity, Ballad was better prepared than the previous smaller hospital systems would have been to address the pandemic – greater purchasing power, for example, and a more unified infrastructure.

Stephanie Stanley, a nurse and the director of the Dickenson County Public Schools’ nursing program, stresses that the pandemic has worsened a challenge Ballad was already facing: a workforce shortage – something hospital systems across the country, especially rural ones, must address. Stanley says many older nurses, at higher risk of contracting the virus, retired early over the past year.

Ballad acknowledged the nursing shortage prior to the pandemic as an “imminent and growing issue.” One measure it took then was to reduce low-acuity hospital admissions – those in which there’s an acceptable outpatient alternative. Whether a system the size of Ballad Health is better equipped to tackle the health care worker shortage into the future remains to be seen.

Rebuilding Bonds

On its website, Ballad Health explains the source of its name: “A ballad is a song that tells a story.” Ballads “help us understand each other. They celebrate our past, give meaning to the present, and help us build a stronger future.”

For some, it’s the obstacles on the path to that stronger, healthier future that have thus far defined Ballad’s tenure – decisions that are perceived as heedless of those most in need.

Ballad is headquartered in Johnson City, Tennessee, and its administrators made decisions early on regarding access that didn’t sit well with many non-Johnson City residents – decisions specifically around the merging of services. Top-level neonatal ICU care was moved from Holston Valley Medical Center in Kingsport to Johnson City Medical Center, 25 miles away; top-level trauma units at the two hospitals were consolidated in Johnson City. For folks in Pennington Gap, in Lee County, that can be an hour-plus drive.

“The risk of death increases by 25 percent if a person isn’t receiving definitive care in a Level I trauma center in the first 60 minutes. That’s the ‘Golden Hour,’” Mickey Spivey, a former Holston Valley ER physician, told The Tennessean. “Rural trauma accounts for some 60 percent of all trauma deaths.”

Sunday morning worship at the Sweet Home Old Regular Baptist Church in Coeburn, Virginia. Old Regular Baptist Churches are declining in numbers but can still be found along the border of Kentucky and Virginia. (Photo by Stacy Kranitz/100 Days in Appalachia)

Another issue is that Ballad has shifted some services from freestanding clinics to hospitals, which means patients must pay an additional facility fee.

And in December 2019, The New York Times reported that Ballad had filed more than 6,700 medical debt lawsuits against patients the previous year. It’s working to address these concerns. Last month, Ballad announced an agreement with RIP Medical Debt to erase almost $278 million in medical debt for some 82,000 people across its service area.

“We’ve started this journey together as a community, and we’re going to work together as one region to write the next chapter of our story together,” Ballad’s website reads. “It’s your story. We’re listening.”

Lee County Community Hospital is now reopened as a 10-bed critical access hospital with an emergency room, diagnostic radiology and lab services, some specialty care and telehealth access. It’s much welcomed.

But there’s mending yet to be done. When Wellmont Health System pulled out of Lee County, it left a lot of resentment in its wake.

“So then you have Ballad come in, and say, ‘We’ll put these broken pieces back together,’” Wendy Welch says, but the decision to close the hospital was made “by the same men who are now going to be taking up senior leadership in the new system.”

Ballad Health, Welch says, “needs to step up its game with listening to community members, but I think they can.”

The people of southwest Virginia certainly hope so. The prevailing attitude is “too soon to tell.”