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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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Sports

If college football’s playoff system ain’t broke, why fix it?

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If college football's playoff system ain't broke, why fix it?

During college football’s Bowl Championship Series era, the sport’s opposition to an expanded, let alone expansive, playoff could be summarized in one colorful quote by then-Ohio State president E. Gordon Gee.

“They will wrench a playoff system out of my cold, dead hands,” Gee said in 2007.

We are happy to report that while college football does, indeed, have a playoff, Gee is still very much alive. The 81-year-old retired just this week after a second stint leading West Virginia University.

What is dead and buried, though, is college football’s staunch resistance to extending its postseason field. After decades of ignoring complaints and the promise of additional revenue to claim that just two teams was more than enough, plans to move from 12 participants to 16 were underway before last season’s inaugural 12-teamer even took place.

A once-static sport now moves at light speed, future implications be damned.

Fire. Ready. Aim.

So maybe the best bit of current news is that college football’s two ruling parties — the SEC and Big Ten — can’t agree on how the new 16-team field would be selected. It has led to a pause on playoff expansion.

Maybe, just maybe, it means no expansion will occur by 2026, as first planned, and college football can let the 12-team model cook a little to accurately assess what changes — if any — are even needed.

“We have a 12-team playoff, five conference champions,” SEC commissioner Greg Sankey said this week. “That could stay if we can’t agree.”

Good. After all, what’s the rush?

The 2025 season will play out with a 12-team format featuring automatic bids for five conference champions and seven at-large spots. Gone is last year’s clunky requirement that the top four seeds could go only to conference champs — elevating Boise State and Arizona State and unbalancing the field.

That alone was progress built on real-world experience. It should be instructive.

The SEC wants a 16-team model but with, as is currently the case, automatic bids going to the champions in the ACC, Big 12, Big Ten, SEC and the best of the so-called Group of 6. The rest of the field would be at-large selections.

The Big Ten says it will not back such a proposal until the SEC agrees to play nine conference games (up from its current eight). Instead, it wants a 16-team system that gives four automatic bids apiece to the Big Ten and SEC, two each to the ACC and Big 12, one to the Group of 6 and then three at-large spots.

It’s been dubbed the “4-4-2-2-1-3” because college athletic leaders love ridiculous parlances almost as much as they love money.

While the ACC, Big 12 and others have offered opinions — mostly siding with the SEC — legislatively, the decision rests with the sport’s two big-dog conferences.

Right now, neither side is budging. A compromise might still be made, of course. The supposed deadline to set the 2026 system is Nov. 30. And Sankey actually says he prefers the nine-game SEC schedule, even if his coaches oppose it.

However, the possibility of the status quo standing for a bit longer remains.

What the Big Ten has proposed is a dramatic shift for a sport that has been bombarded with dramatic shifts — conference realignment, the transfer portal, NIL, revenue sharing, etc.

The league wants to stage multiple “play-in” games on conference championship weekend. The top two teams in the league would meet for the league title (as is currently the case), but the third- and fourth-place teams would play the fifth- and sixth-place teams to determine the other automatic bids.

Extend this out among all the conferences and you have up to a 26-team College Football Playoff (with 22 teams in a play-in situation). This would dramatically change the way the sport works — devaluing the stakes for nonconference games, for example. And some mediocre teams would essentially get a playoff bid — in the Big Ten’s case, the sixth seed last year was an Iowa team that finished 8-5.

Each conference would have more high-value inventory to sell to broadcast partners, but it’s not some enormous windfall. Likewise, four more first-round playoff games would need to find television slots and relevance.

Is anyone sure this is necessary? Do we need 16 at all, let alone with multibids?

In the 12-team format, the first round wasn’t particularly competitive — with a 19.3-point average margin of victory. It’s much like the first round of the NFL playoffs, designed mostly to make sure no true contender is left out.

Perhaps last year was an outlier. And maybe future games will be close. Or maybe they’ll be even more lopsided. Wouldn’t it be prudent to find out?

While there were complaints about the selection committee picking SMU and/or Indiana over Alabama, it wasn’t some egregious slight. Arguments will happen no matter how big the field. Besides, the Crimson Tide lost to two 6-6 teams last year. Expansion means a team with a similar résumé can cruise in.

Is that a good thing?

Whatever the decision, it is being made with little to no real-world data — pro or con. Letting a few 12-team fields play out, providing context and potentially unexpected consequences, sure wouldn’t hurt.

You don’t have to be Gordon Gee circa 2007 to favor letting this simmer and be studied before leaping toward another round of expansion.

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Arch to victory? Texas preseason pick to win SEC

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Arch to victory? Texas preseason pick to win SEC

Texas, with Heisman Trophy candidate Arch Manning set to take over as starting quarterback, is the preseason pick to win the Southeastern Conference championship.

The Longhorns received 96 of the 204 votes cast from media members covering the SEC media days this week to be crowned SEC champion on Dec. 6 in Atlanta at Mercedes-Benz Stadium. Georgia, with 44 votes, received the second-most votes.

If that scenario plays out, it would mean a rematch of the 2024 SEC championship game, which Georgia won in an overtime thriller. The SEC championship game pits the two teams with the best regular-season conference record against one another.

Alabama was third with 29 votes, while LSU got 20. South Carolina was next with five, while Oklahoma received three and Vanderbilt and Florida each got two votes. Tennessee, Ole Miss and Auburn each received one vote.

Since 1992, only 10 times has the predicted champion in the preseason poll gone on to win the SEC championship.

The 2024 SEC title game averaged 16.6 million viewers across ABC and ESPN, the fourth-largest audience on record for the game. The overtime win for Georgia, which peaked with 19.7 million viewers, delivered the largest audience of the college football season.

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World

Every shop and home burned or ransacked: The Syrian city engulfed in tribal violence

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Every shop and home burned or ransacked: The Syrian city engulfed in tribal violence

The Syrian presidency has announced it’s assembling a special taskforce to try to stop nearly a week of sectarian clashes in the southern Druze city of Sweida.

The presidency called for restraint on all sides and said it is making strenuous efforts to “stop the fighting and curb the violations that threaten the security of the citizens and the safety of society”.

By early Saturday morning, a ceasefire had been confirmed by the US special envoy for Syria, Tom Barrack, who posted on X that Syrian President Ahmed al Sharaa and Israeli Prime Minister Benjamin Netanyahu had agreed to a ceasefire supported by US secretary of state Marco Rubio.

The post went on to state that this agreement had the support of “Turkey, Jordan and its neighbours” and called upon the Druze, Bedouins, and Sunni factions to put down their arms.

Sky News special correspondent Alex Crawford reports from the road leading to Sweida, the city that has become the epicentre of Syria’s sectarian violence.

For the past 24 hours, we’ve watched as Syria‘s multiple Arab tribes began mobilising in the Sweida province to help defend their Bedouin brethren.

A fighter aims a gun
A body is wrapped in a blanket

Thousands travelled from multiple different Syrian areas and had reached the edge of Sweida city by Friday nightfall after a day of almost non-stop violent clashes and killings.

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“We have come to protect the [Arab] Bedouin women and children who are being terrorised by the Druze,” they told us.

A fighter in Syria
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Arab fighters said they had come to protect the Bedouin women and children

Fighters at a gas station
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Fighters at a petrol station

Every shop and every home in the streets leading up to Sweida city has been burned or ransacked, the contents destroyed or looted.

We saw tribal fighters loading the back of pickup trucks and driving away from the city with vehicles packed with looted goods from Druze homes.

A burning building
Image:
Shops and homes leading up to Sweida city have been burned or ransacked

A burned out car

Several videos posted online showed violence against the Druze, including one where tribal fighters force three men to throw themselves off a high-rise balcony and are seen being shot as they do so.

Doctors at the nearby community hospital in Buser al Harir said there had been a constant stream of casualties being brought in. As we watched, another dead fighter was carried out of an ambulance.

The medics estimated there had been more than 600 dead in their area alone. “The youngest child who was killed was a one-and-a-half-year-old baby,” one doctor told us.

A doctor talks to Sky's Alex Crawford
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Doctors said there had been a constant stream of casualties due to violence

The violence is the most dangerous outbreak of sectarian clashes since the fall of the Bashar al Assad regime last December – and the most serious challenge for the new leader to navigate.

The newly brokered deal is aimed at ending the sectarian killings and restoring some sort of stability in a country which is emerging from more than a decade of civil war.

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