JOHNSON CITY, Tenn. (WJHL) – Ballad Health CEO Alan Levine submitted a letter to the Centers of Medicare and Medicaid Services requesting changes to the federal COVID-19 vaccine requirements in healthcare facilities Monday, citing long-term staffing challenges in the system.

You can read the full letter below:

In the letter, Levine outlines some of the conditions the Ballad Health System has faced through the COVID-19 pandemic. Levine said that after the first wave of cases through the region, nursing turnover has reached as high as 27%.

One major contributing factor, Levine said, is the mass movement of nurses to contract staffing agencies rather than full-time positions within the system itself.

“If the work is going to be this stressful, due to the combination of staffing shortages and increased volume of seriously ill patients,” Levine said. “The attraction of going elsewhere and being compensated as much as three or four times what full-time staff nurses are paid becomes too difficult to ignore. This cycle has become almost impossible to overcome on our own.”

In addition, Levine said that Ballad’s subsequent wage increases and a sharp rise in costs for contract labor have resulted in operating costs that are not sustainable.

At the time of writing, Levine stated that there were “more than 600 nursing position openings” in the Ballad system. He wrote that before the holiday season, nearly 400 of those open positions were being filled with contract laborers.

Levine’s concern for additional shortages arises out of the Omnibus COVID-19 Health Care Staff Vaccination interim final rule (IFR) submitted by the Department of Health and Human Services.

The guidelines, drafted by the Centers of Medicare and Medicaid Services (CMS), would eventually require full vaccination of all Ballad staff within hospitals and other facilities. Levine said in November 2021, when the system was preparing to put the vaccine mandate into effect before it was halted in court, there were 2,000 Ballad employees who had not been vaccinated and not requested a medical or religious exemption.

“With approximately 13,000 total employees, this would amount to 15 percent of our workforce which would be impacted if the current version of the IFR was finalized,” Levine wrote. “If Ballad Health were to terminate even a fraction of these employees, or if the employees were to resign over concerns with being required to take the vaccine, this would harm our health system’s ability to operate. The employees who are refusing the vaccine include employees in nursing, housekeeping, food service, and other critical positions.”

Should the IFR be finalized as it is, Levine said Ballad could reach a point of being forced to turn away patients or scale back what services are available.

Levine stated that while the mandates have proven to be effective in some parts of the U.S., he asked that administrators consider the cultural differences among various geographic sections of the country.

While Levine wrote that Ballad Health understands the value of COVID-19 vaccines and knows they are safe and effective, he said less than half of the population in the hospital system’s service area has been fully vaccinated.

“For various reasons, our region has a high level of vaccine hesitancy. This includes a high level of vaccine hesitancy among nurses,” Levine wrote.

It is estimated that more than 95% of the nurses employed by Ballad Health are fully vaccinated, but only a rough 60% of non-physician employees are fully vaccinated, according to Levine.

“If CMS finalizes the IFR without acknowledging the impact this could have on existing labor shortages, rural health systems will be forced to terminate thousands of employees who are not comfortable taking the vaccine and our communities will suffer greatly,” Levine wrote.

In the letter, Levine states that the timelines for compliance with the mandate would require shots to be started by the end of January, which he says falls after the predicted peak of the omicron variant surge and would fail to help in a timely manner. In addition, Levine said the health system expects challenges to be heightened by the latest flu strain.

The letter suggested the following courses of action to help rural healthcare providers who would be adversely affected by the CMS mandate:

  • CMS should consider permitting hospitals in health professional shortage areas to seek waivers from the mandate if they can demonstrate difficulties with retention of staff. Those parts of the country which already suffer from shortages, and which are disadvantaged in terms of recruitment and retention, need to first do no harm in terms of staffing availability. Permitting health systems that can demonstrate staff retention challenges to seek waivers would be fair and would appropriately recognize the importance of balancing appropriate staffing levels at healthcare facilities with the administration’s desire to increase vaccination rates among healthcare workers.
  • In the absence of offering the option to seek a waiver, CMS should delay implementation of the vaccine mandate at least through June for facilities located in health professional shortage areas. This will allow facilities located in the areas with the greatest healthcare workforce shortages time to implement policies and procedures aimed at improving vaccination rates. This will also help ensure that individuals who are living in rural communities are not disproportionately impacted by staffing shortages that may occur as a result of employees refusing the vaccine.
  • CMS should take a flexible approach to surveying for compliance with the vaccine mandate and allow providers to show that if they are not compliant, the lack of compliance is due to the facility prioritizing appropriate levels of staffing to care for the needs of the community it is responsible for serving. An important part of the mission of CMS is to ensure high quality care provided through compliance with the conditions of participation. If a provider can demonstrate that a condition of participation could materially undermine quality of care or access to care, then the priority of the survey should be to ensure the licensed entity is taking all appropriate steps to mitigate that which undermines quality of care or access. Thus, if the facility determines that terminating a material number of employees can impair its ability to keep the facility clean, feed its patients, or provide appropriate and safe levels of staffing for direct care, this determination should be considered before penalizing the licensed entity.
  • CMS should direct state survey agencies to verify the presence of policies and procedures related to the IFR and verify they are being followed. However, assessing the appropriateness of medical or religious exemptions is beyond a surveyor’s expertise and should not be included in the scope of surveys for compliance.
  • CMS should remove the administrative burden it has placed on healthcare facilities to verify COVID-19 vaccinations for contractors and vendors. Healthcare facilities should not be asked to take on the compliance burden of verifying the vaccination status of third parties.
  • CMS should allow staff who have received one dose of the COVID-19 vaccine to perform their jobs while they await their second dose so long as they are complying with policies to minimize the risk of transmission (e.g., PPE, testing, social distancing, etc.). This will help preserve workforce levels as we encourage higher levels of vaccination.
  • CMS should make it clear that the definition of “fully vaccinated” for purposes of compliance with the CMS mandate does not include boosters.

At the conclusion of his letter, Levine thanked the CMS for its previous flexibility and expressed hope that that would continue.