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In rural Appalachia, Ballad Health faces unique virus challenges

In rural Appalachia, Ballad Health faces unique virus challenges


Ballad Health on Tuesday reported that its first patient, a Tennessee man in his 70s, had died from the new coronavirus.

“It was a pretty fast demise and everything we have been told to expect,” CEO Alan Levine said during a news briefing.

Ballad is the predominant health care provider to people living in Tennessee’s northeastern Tri-Cities region and Virginia’s coalfields.

Until this week, about half of Ballad’s patients who tested positive for the virus were in their 20s and 30s, but that is changing. Ballad now has 57 positive cases, with 15 of the results coming between Monday and Tuesday, and with them a big shift: 11 of the patients are older than 50.

Many of the early cases were travel-related and followed the overall trend in Tennessee in which the virus initially infected younger people.

Virginia’s COVID-19 story has differed from its neighbor’s.

Tennessee has more cases overall, with 1,834 positive tests as of Tuesday, compared with Virginia’s 1,250. But it has had fewer hospitalizations, 148 to Virginia’s 165, and fewer deaths, 13 to Virginia’s 27. The disease is milder in younger people. In Tennessee, on Tuesday 41% of the cases were in adults under 40, a significantly higher rate than in Virginia where 28% of the cases were in that age range.

Levine sees the story changing quickly in Tennessee as more elderly residents are becoming ill. Age and underlying medical conditions like heart and lung diseases, diabetes and high blood pressure place people at a greater risk for the respiratory disease to cause severe symptoms and death.

Levine appeared impatient with people who have failed to heed warnings by both governors and public health officials to stay home.

“The bottom line is if you knowingly put yourself in a position to spread this disease, that is the definition of abject stupidity. I just don’t know how more clearly to say it. This is a disease that is killing people,” he said. “We’ve seen how horrible these symptoms are for the many people who get it. Whether you are ordered by a governor, or not, if you put yourself in a position to unnecessarily expose yourself or other people, you are not being smart.”

Levine said four Ballad health care workers have the disease. All of them are doing well, and one has recovered enough to return to work. He said that employee works part of his day from home in order to comply with social distancing.

“Imagine if you’re the person that’s responsible because you came into contact with 15 people, and five of those are elderly, and three of those people died. How would you feel about that? Whether the governor orders it or not, it’s up to each of us to be responsible,” Levine said.

In Ballad’s Virginia region, the state health department has reported two positive cases each in Lee, Washington and Tazewell counties, and one each in Bristol and Smyth County, the latter a worker at the state’s psychiatric hospital.

Running models

Ballad is attempting to run models to figure out how steeply its cases might rise and how soon the system would be overrun.

“If we don’t mitigate the spread now, there is not enough capacity,” Levine said.

Ballad plans to provide highly skilled care at its regional hospitals – Johnson City Medical Center, Holston Valley and Bristol Regional – where it has intensive care units and the ability to set up 230 beds for COVID-19 patients.

For those who need hospital care but not at a high level, Ballad plans to treat and quarantine COVID-19 patients at Lonesome Pine Hospital in Big Stone Gap. Patients without the disease will be treated at Norton Community, Ballad’s other Wise County hospital.

Lonesome Pine’s emergency room will remain open, but all other services are shifting to Norton Community.

Ballad plans to create a similar setup in Greene County, Tennessee, where it has two hospitals.

Population health officer Tony Keck said in a phone interview last week that Ballad is looking at a few different models to predict what might occur, as well as the health system’s capacity and needs.

“It’s tough in the beginning with something like this because you don’t have trends, and you don’t know how many cases are already in the community because the testing is just getting ramped up,” Keck said.

And it’s hard to know what will occur in a rural mountainous region where, outside of church, large groups of people come together less often than in urban areas, creating a sort of natural social distancing.

“Maybe our social distancing is working for us, and our generally older population might work against us. So that’s all part of the modeling exercise,” he said.

Levine said Tuesday that models assume the rate of cases in the area will double every six days, and will have patients exceeding Ballad’s planned-for capacity in 40 to 70 days.

He said they are working with East Tennessee State University and the Army Corps of Engineers to figure out what to do if the trajectory doesn’t change.

Looking to the future

Keck is looking even further ahead to after the threat passes, and to what health care might look like in its aftermath.

Ballad Health entered the pandemic with between 250 and 260 days cash on hand, which was reduced by 40 or 50 days when the stock market tanked. Also, Ballad stopped performing all nonessential procedures in order to both save on personal protective equipment and reduce the spread of the disease.

“Those non-emergent elective procedures, which are essentially surgery and imaging, are actually how most hospitals make their money,” Keck said. “The loss of those procedures could be a hit to our bottom line of over nine figures in the next few months, which is putting sustainability of the health systems around the country at risk.”

Ballad officials made sure their congressional delegations in both states understood the potential financial hardship as they worked on last week’s federal assistance package.

Keck said that Ballad, as a large system, is in a much better position than smaller, rural hospitals, both financially and in its ability to purchase supplies in bulk. The 2018 merger of two health systems that created Ballad allowed the health system to consolidate services. It is also able to turn excess building capacity into wings to care for COVID-19 patients.

That’s a luxury many systems don’t have.

“I’m the chief population health officer, and I’m very much focused on getting people upstream into primary care and preventative care because it keeps them healthier and it’s less costly to them and to the system,” he said.

“The entire U.S. health care system has been moving that direction for a lot of years, and we’ve been wringing out a lot of extra capacity. The problem is that health care systems need to be there for these types of surges, so when you reduce hospital beds all over the country in the name of cost control, what we are finding is a lot of communities no longer have that excess capacity whether it is beds or staff to work for something like this.”

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