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A Tennessee agency that is supposed to hold accountable and grade the nations largest state-sanctioned hospital monopoly awards full credit on dozens of quality-of-care measurements as long as it reports any value regardless of how its hospitals actually perform.

This story also ran on States Newsroom. It can be republished for free.

Ballad Health, a 20-hospital system in northeast Tennessee and southwest Virginia, has received A grades and an annual stamp of approval from the Tennessee Department of Health. This has occurred as Ballad hospitals consistently fall short of performance targets established by the state, according to health department documents.

Because the states scoring rubric largely ignores the hospitals performance, only 5% of Ballads final score is based on actual quality of care, and Ballad has suffered no penalty for failing to meet the states goals in about 50 areas including surgery complications, emergency room speed, and patient satisfaction.

It doesnt make any sense, said Ron Allgood, 75, of Kingsport, Tennessee, who said he had a heart attack in a Ballad ER in 2022 after waiting for three hours with chest pains. It seems that nobody listens to the patients.

Ballad Health was created six years ago after Tennessee and Virginia lawmakers waived federal anti-monopoly laws so two competing hospital companies could merge. The monopoly agreement established two quality measures to compare Ballads care against the states baseline expectations: about 17 target measures, on which hospitals are expected to improve and their performance factors into their grade; and more than 50 monitoring measures, which Ballad must report, but how the hospitals perform on them is not factored into Ballads grade.

Ballad has failed to meet the baseline values on 75% or more of all quality measures in recent years and some are not even close according to reports the company has submitted to the health department.

Since the merger, Ballad has become the only option for hospital care for most of about 1.1 million residents in a 29-county region at the nexus of Tennessee, Virginia, Kentucky, and North Carolina. Critics are vocal. Protesters rallied outside a Ballad hospital for months. For years, longtime residents like Allgood have alleged Ballads leadership has diminished the hospitals theyve relied on their entire lives.

Its a shadow of the hospital we used to have, Allgood said. Protesters gather in opposition to the closure of the neonatal intensive care unit at Holston Valley Medical Center, a Ballad Health hospital, in 2019. (Dani Cook) Email Sign-Up

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And yet, every year since the merger, the Tennessee health department has reported that the benefits of the hospital merger outweigh the risks of a monopoly, and that Ballad continues to provide a Public Advantage. Tennessee has also given Ballad an A grade in every year but two, when the scoring system was suspended due to the covid-19 pandemic and no grade issued.

The departments latest report, released this month, awarded Ballad 93.6 of 100 possible points, including 15 points just for reporting the monitoring measures. If Tennessee rescored Ballad based on its performance, its score would drop from 93.6 to about 79.7, based on the scoring rubric described in health department documents. Tennessee considers scores of 85 or higher to be satisfactory, the documents state.

Larry Fitzgerald, who monitored Ballad for the Tennessee government before retiring this year, said it was obvious the states scoring rubric should be changed.

Fitzgerald likened Ballad to a student getting 15 free points on a test for writing any answer.

Do I think Ballad should be required to show improvement on those measures? Yes, absolutely, Fitzgerald said. I think any human being you spoke with would give the same answer.

Ballad Health declined to comment. Tennessee Department of Health spokesperson Dean Flener declined an interview request and directed all questions about Ballad to the Tennessee Attorney Generals Office, which also has a role in regulating the monopoly. Amy Wilhite, a spokesperson for the AGs office, directed those questions back to the health department and provided documents showing it is the agency responsible for how Ballad is scored.

The Virginia Department of Health, which is also supposed to perform active supervision of Ballad as part of the monopoly agreement, has fallen several years behind schedule. Its most recent assessment of the company was for fiscal year 2020, when it found that the benefits of the monopoly outweigh the disadvantages. Erik Bodin, a Virginia official who oversees the agreement, said more recent reports are not yet ready to be released.

Ballad Health was formed in 2018 after state officials approved the nations biggest so-called Certificate of Public Advantage, or COPA, agreement, allowing a merger of the Tri-Cities regions only two hospital systems Mountain States Health Alliance and Wellmont Health System. Nationwide, COPAs have been used in about 10 hospital mergers over the past three decades, but none has involved as many hospitals as Ballads.

The Federal Trade Commission has warned that hospital monopolies lead to increased prices and decreased quality of care. To offset the perils of Ballads monopoly, officials required the new company to agree to more robust regulation by state health officials and a long list of special conditions, including the states quality-of-care measurements.

Ballad failed to meet the baseline on about 80% of those quality measures from July 2021 to June 2022, according to a report the company submitted to the health department. The following year, Ballad fell short on about 75% of the quality measures, and some got dramatically worse, another company report shows.

For example, the median time Ballad patients spend in the ER before being admitted to the hospital has risen each year and is now nearly 11 hours, according to the latest Ballad report. That’s more than three times what it was when the monopoly began, and more than 2.5 times the state baseline.

And yet Ballads grade is not lowered by the lack of speed in its ERs.

Fitzgerald, Tennessees former Ballad monitor, who previously served as an executive in the University of Virginia Health System, said a hospital company with competitors would have more reason than Ballad to improve its ER speeds.

When I was at UVA, we monitored this stuff passionately because and I think this is the key point here we had competition, Fitzgerald said. And if we didnt score well, the competition took advantage.

Midwest correspondent Samantha Liss contributed to this report.

Brett Kelman: bkelman@kff.org, @BrettKelman Related Topics Health Industry States Hospitals Tennessee Virginia Contact Us Submit a Story Tip

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Police foil bomb plot targeting Lady Gaga’s biggest-ever show on Copacabana beach

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Police foil bomb plot targeting Lady Gaga's biggest-ever show on Copacabana beach

Brazilian police say they foiled a bomb attack planned for a Lady Gaga concert on Rio de Janeiro’s Copacabana beach that attracted an estimated 2.1 million people.

The plot was orchestrated by a group promoting hate speech and the radicalisation of teenagers, including self-harm and violent content as a form of social belonging, according to the Civil Police of Rio de Janeiro, which worked in coordination with the country’s justice ministry.

“The suspects were recruiting participants, including minors, to carry out coordinated attacks using improvised explosives and Molotov cocktails,” the force said.

The justice ministry said the recruiters identified themselves as Gaga’s fans, known as “Little Monsters”.

It said Operation Fake Monster was based on a report by the ministry’s cyber operations lab following a tip-off from Rio state police intelligence, which uncovered digital cells encouraging violent behaviour among teenagers using coded language and extremist symbolism.

Authorities carried out over a dozen search and seizure warrants, and a man described as the group’s leader was arrested in the southern state of Rio Grande do Sul for illegal possession of a firearm, and a teenager was detained in Rio de Janeiro for storing child abuse images.

Lady Gaga performing at the huge open-air concert. Pic: Reuters
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Lady Gaga performing at the huge open-air concert. Pic: Reuters

Gaga’s biggest ever show

Some 500,000 tourists travelled to watch the concert, which was paid for by the city in an attempt to boost the struggling economy.

Saturday night’s two-hour show, which marked Gaga’s biggest ever, marked the first time she had played in Brazil since 2012, having cancelled an appearance at the Rock in Rio festival in 2017 over health issues.

Gaga, who released her seventh studio album, Mayhem, in March, opened with a dramatic, operatic edition of her 2011 track Bloody Mary, before launching into Abracadabra, a recent track.

Lady Gaga performs during her free concert on Copacabana Beach in Rio de Janeiro, Saturday, May 3, 2025. (AP Photo/Silvia Izquierdo)
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Pic: AP

Lady Gaga, centre, performs during her free concert on Copacabana Beach in Rio de Janeiro, Saturday, May 3, 2025. (AP Photo/Silvia Izquierdo)
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Pic: AP

“Brazil! I missed you. I missed you so much,” she exclaimed, before launching into Poker Face, one of her biggest hits.

The American pop star drew in a similar crowd to Madonna’s in May last year, who performed at the same beach, which is transformed into an enormous dance floor for the shows.

Addressing the crowd in English and through a Portuguese translator, Gaga became emotional as she said: “I’m so honoured to be here with you tonight.

People attend Lady Gaga's open concert at Copacabana beach in Rio de Janeiro, Brazil, May 3, 2025. REUTERS/Tita Barros
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Gaga addresses the crowd. Pic: Reuters

Gaga seen performing on giant screens set up across the beach. Pic: Reuters
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Gaga seen performing on giant screens set up across the beach. Pic: Reuters

“Tonight we’re making history, but no one makes history alone. Without all of you, the incredible people of Brazil, I wouldn’t have this moment. Thank you for making history with me.

“The people of Brazil are the reason I get to shine today. But of all the things I can thank you for, the one I most am grateful for is this: that you waited for me. You waited more than 10 years for me.”

She said it took so long to come back because she was “healing” and “getting stronger”. The pop sensation cancelled many of her shows in 2017 and 2018 due to her fibromyalgia condition, which can cause pain and fatigue.

It is estimated Gaga’s show will have injected around 600 million reais (£79.9m) into the economy, nearly 30% more than Madonna’s show.

People gather to attend Lady Gaga's open concert, in Copacabana beach in Rio de Janeiro, Brazil May 3, 2025. REUTERS/Pilar Olivares
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Pic: Reuters

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The large-scale free shows are set to continue annually until at least 2028, always taking place in May, which is considered the economy’s “low season”, according to the city’s government.

A hefty security plan was in place, including the presence of 3,300 military and 1,500 police officers, along with 400 military firefighters.

‘A dream come true’

Fans find a spot to watch the show. Pic: AP
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Pic: AP

The city has been swarmed with Gaga fans since her arrival on Tuesday, with some even keeping vigil outside of the hotel she has been staying at.

Many arrived at the beach at the crack of dawn on Saturday to secure good spots on the beach, despite the show not starting until 9.45pm.

An aerial view shows fans gathering on Copacabana beach ahead of Lady Gaga's arrival. Pic: Reuters
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An aerial view shows fans gathering on Copacabana beach ahead of Lady Gaga’s arrival. Pic: Reuters

Ana Lara Folador, who attended with her sister, said it was “a dream come true”, and that Gaga had “really shaped a part of my personality, as a person and an artist”.

Ingrid Serrano, a 30-year-old engineer who made a cross-continent trip from Colombia to Brazil to attend the show, turned up in a T-shirt featuring Lady Gaga’s outlandish costumes over the years.

“I’ve been a 100% fan of Lady Gaga my whole life,” she said, adding the 39-year-old megastar represented “total freedom of expression – being who one wants without shame”.

A fan dons an unusual face mask. Pic: AP
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A fan dons an unusual face mask. Pic: AP

A fan strikes a pose. Pic: AP
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A fan strikes a pose. Pic: AP

Matheus Silvestroni, 25, an aspiring DJ and a Gaga fan since the age of 12, endured an eight-hour bus ride from Sao Paulo for the show.

He said it was Gaga who had inspired him to embrace his sexuality and pursue his dream of becoming an artist.

“I was bullied because I was a fat, gay kid, so I was an easy target,” he said. “Gaga was very important because she sent a message that everything was okay with me, I wasn’t a freak, because I was ‘Born This Way’.”

Rio is known for holding massive open-air concerts, with Rod Stewart holding a Guinness World Record for the four million-strong crowd he drew to Copacabana beach in 1994.

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John Lithgow on JK Rowling’s trans stance backlash: ‘She’s handled it fairly gracefully’

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John Lithgow on JK Rowling's trans stance backlash: 'She's handled it fairly gracefully'

John Lithgow is a man well aware of cancel culture and its ability to destroy careers in the blink of an eye.

The Oscar-nominated actor tells Sky News: “It is terrible to be so careful about what you say. Even in an interview like this. It goes into the world, and you can get misconstrued and misrepresented and cancelled in [the click of a finger].”

Pic: Johan Persson
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Roald Dahl is the subject of West End play Giant, by Mark Rosenblatt. Pic: Johan Persson

It’s a theme that runs parallel with his latest work – the stage show Giant – which through the lens of one explosive day in children’s author Roald Dahl‘s life, poses the question, should we look for moral purity in our artists?

The writer of great works including The Witches, Matilda and The BFG, Dahl revolutionised children’s literature with his irreverent approach, inspiring generations of readers and selling hundreds of millions worldwide. But his legacy is conflicted.

Lithgow describes Dahl as “a man with great charm, great wit and literary talent. A man who really cared about children and loved them. But a man who carried a lot of demons.”

Specifically, the play – which explores Palestinian rights versus antisemitism – deals with the fallout from controversial comments the children’s author made over the Israeli invasion of Lebanon in 1982. Its themes couldn’t be more timely.

Lithgow explains: “Things are said in the play that nobody dares to say out loud… But God knows this is a complicated and contradictory issue.”

More on Jk Rowling

Pic: Johan Persson
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John Lithgow plays Dahl – a man capable of ‘great compassion’ and ‘enormous cruelty’. Pic: Johan Persson

‘It didn’t start as an idea about Roald Dahl at all’

So controversial are some of the play’s themes, the 79-year-old star admits his own son warned him: “Prepare yourself. There’ll be demonstrations in Sloane Square outside the Royal Court Theatre.”

Indeed, the play’s first run carried an audience warning flagging “antisemitic language; graphic descriptions of violence; emotional discussion of themes including conflict in the Middle East, Israel and Palestine; and strong language”.

But it didn’t put audiences off. Following a sold-out run at the Royal Court, the role won Lithgow an Olivier. Now, it’s transferring to London’s West End.

The play was written by Mark Rosenblatt, a seasoned theatre director but debut playwright.

He tells Sky News: “It didn’t start as an idea about Roald Dahl at all. It was about the blurring of meaningful political discourse with racism, specifically when, in 2018, the inquiry into antisemitism in the Labour Party started to come out.”

Rosenblatt describes Dahl’s Revolting Rhymes and Dirty Beasts as the “wallpaper” of his childhood, and says he had no desire to “smash the Roald Dahl pinata”.

But despite the fond recollections, he was conflicted: “Understanding that [Dahl] also, possibly, didn’t like someone like me because I’m Jewish felt complicated.” It was Rosenblatt’s exploration of “how you hold those two things at the same time” that led to Dahl becoming the play’s focus.

Elliot Levey plays Dahl's Jewish publisher, and Aya Cash plays an American Jewish sales executive. Pic: Johan Persson
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Elliot Levey plays Dahl’s Jewish publisher, and Aya Cash plays an American Jewish sales executive. Pic: Johan Persson

‘He’s not cancelled in our home’

Rosenblatt describes him as “a complex man, capable of great compassion, great passionate defence of oppressed people, and also capable of enormous cruelty and manipulation. He was many things at once”.

And as for Dahl’s place in his life now? Rosenblatt says: “I still read his books to my kids. He’s certainly not cancelled in our home.”

It’s likely that Dahl’s comments, if uttered today, would lead to swift social media condemnation, but writing in a pre-social media age, the judgment over his words came at a much slower pace.

Dahl died in 1990, and his family later apologised for antisemitic remarks he made during his lifetime. But the debate of whether art can be separated from the artist is still very much alive today.

Earlier this month, Lithgow found himself drawn into a different row over artists and their opinions – this time concerning author JK Rowling.

Author and Lumos Foundation founder J.K. Rowling attends the HBO Documentary Films premiere of ...Finding the Way Home" at 30 Hudson Yards on Wednesday, Dec. 11, 2019, in New York. (Photo by Evan Agostini/Invision/AP)
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JK Rowling in 2019. Pic:AP

‘A matter of nuance’

Soon to play Dumbledore in the Harry Potter TV series, he has been criticised by some fans for working with the author known for her gender critical beliefs.

Lithgow told Sky News: “It’s a question I’m getting asked constantly. I suppose I should get used to that, but JK Rowling has created an amazing canon of books for kids…

“I have my own feelings on this subject. But I’m certainly not going to hesitate to speak about it. Just because I may disagree… It’s a matter of nuance… I think she’s handled it fairly gracefully.”

The actor ignored calls not to take the role.

He goes on: “Honestly, I’d rather be involved in this than not. And if I’m going to speak on this subject, I’m speaking from inside this project and very much a partner with JK Rowling on it.”

Demanding an eight-year commitment and a move to the UK for the part, the stakes are high.

And with a legion of Harry Potter fans watching on from the wings, only time will tell if the Lithgow-Rowling partnership will prove a magical one.

Giant is playing at the Harold Pinter Theatre in London until Saturday, 2 August.

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Lorraine Kelly says she will undergo surgery to remove ovaries

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Lorraine Kelly says she will undergo surgery to remove ovaries

Lorraine Kelly has revealed she is undergoing surgery to remove her ovaries and fallopian tubes.

The 65-year-old TV presenter posted a video of her in a hospital bed on Instagram, and said “I’ve not been feeling all that well for a little while”.

Kelly added she “had a little scan and I have to have my ovaries and my tubes taken out” with keyhole surgery.

She said that the procedure is “purely preventative,” and that “I’m going to be totally fine, see you soon”.

According to the NHS, keyhole surgery – also called laparoscopic surgery – is carried out using several small incisions.

The procedure can take between one and two hours, and doctors recommend staying off work for two to four weeks after the surgery.

In the caption, the ITV presenter wrote she felt “very lucky to be treated so well” and thanked gynaecologist Dr Ahmed Raafat and hospital staff.

More on Lorraine Kelly

Good Morning Britain presenter Susanna Reid said she was “sending you all the love in the world”, while TV presenter Julia Bradbury added: “Wishing you a speedy recovery Lorraine, and good luck with the post op rehab.”

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Kelly has been in television since 1984, starting her career on TV-am as an on-screen reporter covering Scottish news.

In 1990, she began her presenting career on Good Morning Britain, before hosting her own show, Lorraine, from 2010.

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