Ballad Health reports nine-month results: Strong financial performance, capital investment and major regional collaboration

In first nine months of fiscal year, Ballad Health turns combined losses of previously independent health systems into operating gains, continues high quality performance and capital investment

Ballad Health today announced quality, investment and financial results from its first nine months of the fiscal year, and quarterly results for the third quarter.   

“Ballad Health’s  third quarter operational performance was strong due to the focus by our team members and affiliated physicians on delivering excellent care while being good stewards of these important health care institutions,” said Alan Levine, chairman, president and chief executive officer of Ballad Health. “I am proud of the focus on quality and collaboration with the community, and we continue to see that improved quality leads to lower cost and positive financial performance for our health system.”

Ballad Health last week announced a $10 million investment into increasing direct care nursing and nursing support salaries, a direct result of improved financial performance.  

“Since the productivity of our nursing staff has been a major contributor to our success, we believe it is appropriate to reinvest in our nurses and those who support them in direct patient care,” said Levine.

“The board of directors of Ballad Health is pleased with the operating performance of our region’s health system, and in particular, with the focus on quality and outcomes,” said David Lester, a member of the board of directors and lead independent director. “Our board and management team remain focused on implementing the vision of the merger. While this task is not always easy, as board members we want the best for our region.” 

Compliance with the regulatory terms of the merger, and community collaboration

Last week, the Tennessee Department of Health released its annual report of the Terms of Certification of the merger that created Ballad Health. The state reported that Ballad Health is in compliance with the Terms of Certification. Among the health system’s successes, the state noted: 

• Ballad Health’s prompt compliance with the state’s requests for data and information;  
• Hospitals which were under threat of closure remain open, countering a widely reported national trend of rural hospital closures; 
• Fewer layoffs than expected; 
• Compliance with reporting requirements; 
• Thorough responses to compliance inquiries from the Ballad Health compliance functions;  
• Innovative and successful solutions to consolidation of hospitals in a market that had previously seen more than $70 million in operating losses in the five years prior to the merger; and 
• Submission of plans with “bold approaches to improving population health, children’s health, behavioral health access, rural health access, region-wide health information exchange, health graduate research, and graduate medical education in the region.

Importantly, the Tennessee Department of Health stated it is “particularly impressed by the Accountable Care Community that Ballad Health is playing a lead role in establishing in the region.”

Ballad Health has facilitated what may be the nation’s largest Accountable Care Community ACC, spanning two states. The ACC reflects involvement from more than 200 local community organizations, churches, businesses and not-for-profits, and is poised to partner with Ballad Health, the State of Tennessee and the Commonwealth of Virginia to identify key opportunities for improving the health of the community. This collaboration is the direct result of Ballad Health’s investment into the creation of a dedicated population health department, led by experts in public health and community outreach. This infrastructure was agreed to in the Terms of Certification, and was one of the first accomplishments of Ballad Health.  

In addition to the creation of this innovative collaboration, Ballad Health also remains focused on qualitative improvements in care. Led by the Ballad Health Clinical Council – a group comprising dozens of physicians from throughout the region – Ballad Health has implemented a number of initiatives that have led to the reduction of hospital acquired conditions. Key successes of the Clinical Council include:

• Pressure ulcer rates have declined by as much as 17%
• Iatrogenic pneumothorax rate has declined by as much as 58%
• Central venous catheter-related blood stream infection rate has declined as much as 40%
• Perioperative hemorrhage or hematoma rate has declined by as much as 65%
• Postoperative respiratory failure rate has declined as much as 44%
• Clostridium Difficile rate has declined by as much as 41%
• Postoperative sepsis rate has declined by as much as 70%
• Inpatient opioid administration rate has declined by as much as 36%
• Median time from ED arrival to departure has improved by as much as 13%
• Median time from ED arrival to transport for admitted patients improved by as much as 30%
• Patients who reported their nurses “always” communicated well improved by as much as 8%

“The efforts to deliver high quality are always ongoing, and while the results may change from month to month, we are clearly seeing trends which are favorable,” said Levine. 

Ballad Health’s Clinical Council, a system-wide physician-led effort to help Ballad Health excel in improved quality, reduced cost and increased physician engagement, has taken active participation in prioritizing Ballad Health becoming a top-decile, zero harm health system in the nation. Chaired by Dr. Amit Vashist, the Clinical Council has already led the health system to recognition for its efforts in value-based services. Ballad Health was selected by the High Value-Care Collaborative to participate with leading health systems to adopt strategies that will reduce unnecessary cost and deliver evidence-based care demonstrated to reduce the burden on patients. The High Value-Care Collaborative is a joint project between the American Hospital Association, the American Board of Internal Medicine Foundation’s Choosing Wisely Campaign and the Costs of Care organization.  

Financial strength

“We know that in order to fulfill the vision of Ballad Health – to truly become a health improvement organization for our region – we must be strong stewards of our resources, especially given the headwinds all providers are facing,” said Levine. “We are pleased by the strong financial performance improvements over the past three quarters and will strive to continue to improve.”

Quarterly highlights include:

• Operating cash flow (Operating EBITDA) for the quarter improved to $55.5 million from $46.7 million in the same quarter prior year, a 18.7 percent increase.  
• Total cash flow (EBITDA) improved to $44.1 million versus $40.3 million in the same quarter prior year, a 9.3 percent increase.   
• Revenue for the quarter increased by 1.4 percent, while expenses decreased by 0.2 percent - leading to an improvement in the operating margins for the health system.
• Operating margin improved significantly to 1.3 percent compared to (0.2) percent for the same quarter last year.  EBITDA margin improved 7.9 percent in the prior year quarter to 8.6 percent in the current year quarter.
• Ballad Health’s financial performance improved in the quarter due to exceptional expense management, including a 31.3 percent reduction in the use of contract – or temporary – labor, improvements in productivity and focused supply cost management. Ballad Health invested $266.3 million into the region’s labor force, making a major economic impact.

Nine-month highlights include:

• For the nine months ended December 31, 2018, operating cash flow improved to $158.7 million from $141.4 million in the prior year, a 12.2 percent improvement.   
• Total cash flow (EBITDA) improved to $169.4 million versus $145 million in the same period prior year, a 16.8 percent increase.    
• Revenue for the nine months increased by 1.3 percent, while expenses increased by 0.4 percent – leading to an improvement in the operating margins for the health system from 0.0 percent to 0.9 percent. 
• The EBITDA margin improved from 9.6 percent in the prior year to 11.1 percent in the current year.  
• Operating income for the nine month period improved to $13.7 million from $(0.405) million in the same period prior year.

Ballad Health’s improved financial performance for the year follows dedicated expense management, improvements in productivity and focused supply cost management.   

Ballad Health’s investment into the region’s labor force continues to be powerful, with Ballad Health expected to spend more than $1 billion on the region’s labor force in the fiscal year. These improvements are in spite of challenges both reflective of what all providers are facing and also some that are unique to Ballad Health and the region. These challenges include:

• Ballad Health continues to see a trend of declining volumes in certain services, with acute discharges declining in the quarter by 5.5 percent. Adjusted discharges in the quarter increased slightly by 0.7 percent due to improved length of stay of inpatients and increased shift to outpatient services. Total surgeries for the quarter decreased by 3.9 percent to 17,547 cases. Inpatient surgeries decreased by 5.4 percent, while outpatient surgeries decreased by 3.3 percent. Emergency department visits declined by 1.0 percent.  
• Ballad Health continues to experience declining inpatient and hospital utilization rates, a phenomenon being experienced throughout rural America. The decline in admissions in Ballad Health’s service area is driven in part by efforts by Ballad Health and area physicians to utilize lower cost alternatives to hospital stays as appropriate. This successful reduction, when combined with low population growth, reduces the overall volumes in the hospital setting. 

“Ballad Health is facing a rapidly changing landscape where our financial success is no longer judged solely by volume, but increasingly, how we care for fewer people more efficiently, effectively and with better outcomes,” said Levine. “Many of the quality metrics that we’ve seen improve have led to lower costs. Lower length of stay, reduced rates of hospital acquired conditions, reduced readmissions and better integration with physicians has helped reduce the cost of care and has helped Ballad Health achieve success with the new value-based purchasing environment.” 

Levine pointed to a 10 percent reduction in the hospital readmission rate over the prior year, and a 25 percent reduction among legacy hospitals since 2015 as evidence that physican and administrative partnership is resulting in lower cost and lower risk to patients. Ballad Health achieved the lowest readmission rate in either legacy health systems’ histories.

Reinvestment of capital throughout the region

While Ballad Health was focused on improved financial performance, it also has continued to invest in capital for new equipment, diagnostic technology, information technology and building improvements. Ballad Health expects to spend more than $172 million on capital improvements in the fiscal year ending in June, 2019.