The Ballard Clinic sits across the street from the Greyhound bus station in the hollowed-out downtown of Jackson, Tenn., a small city about an hour from Memphis. After Dr. Thomas Ballard III took it over from his father, he turned the family medicine practice into a pain clinic. By 2015, it had become a pill mill.
That’s what federal prosecutors alleged when they indicted Dr. Ballard III in 2019 for prescribing 4.2 million pills of opioids out of the Ballard Clinic. They claimed that Dr. Ballard doled out opioids in dangerous combinations with muscle relaxants and benzodiazepines known to abusers as the “holy trinity.”
The feds said he traded drugs for sex. Prosecutors claimed Ballard prescribed opioids to one patient, A.L. — a young woman he had known since she was a girl — before and after she was in drug rehab and even while she was pregnant. She died on May 28, 2015, from an overdose of hydrocodone, which Dr. Ballard had prescribed the day before.
And where in all this was the state’s medical board, the regulatory entity that decides who gets a medical license and who gets to keep it? Two weeks before A.L. overdosed, board investigators had inspected the Ballard Clinic, probably in response to a complaint.
They found 10 violations, including that he was taking cash and money orders for “pain management treatment” and that he was repackaging unused medication to be dispensed to other patients. They asked Ballard for charts and the doctor refused to fully comply. But no action was taken.
The following year, when over 42,000 Americans died of opioid-related overdoses, board investigators came back. They found the same violations. And again the medical board waited.
The year after that, when more than 47,000 more Americans died of overdoses, the Ballard Clinic finally lost its “pain clinic” designation based on the failed inspections. Not having the designation made it technically unlawful for the doctor to see mostly pain patients. But the medical board — the only state regulatory entity able to stop Dr. Ballard’s prescribing — again did nothing.
In 2018 (another 46,000 dead), the medical board finally placed Dr. Ballard’s license on probation. They asked him to pay a fine, attend classes, and stick to the state’s pain-prescribing guidelines. But they did not take away his ability to prescribe controlled substances.
By 2019 — the year nearly 50,000 Americans died from opioid overdoses — it was clear that the board wasn’t going to stop Dr. Ballard. Only a federal indictment could remove the power of his prescription pad. He was finally arrested in April 2019, four years after licensing board investigators first visited the clinic.
At his pretrial release hearing, a federal judge did what the licensing board couldn’t or wouldn’t do: Revoke his authority to prescribe controlled substances. In 2021, Ballard pled guilty to distributing controlled substances not for a legitimate medical purpose, resulting in death. He was sentenced to 20 years in prison.
How did we get here, where it’s easier to go to prison for professional misconduct than lose your license when your patients wind up dead? Medical boards, like all professional licensing boards, are comprised mostly of members of the profession — fellow doctors, lawyers, or nurses.
They are busy, working full time, taking just a few days each year to moonlight as their own regulators. Board seats often go to former leaders of professional associations, where the instinct to circle the wagons is ingrained.
Board members do their best to “change hats” when they go from association to powerful licensing board, but real change is far harder than it seems. Licensing boards’ poor performance in professional discipline bears this out. For example, I found that the Tennessee Medical Board kept in practice more than two-thirds of prescribers found to have engaged in over-prescribing controlled substances, even at the height of the opioid crisis.
In recent years, the criminal justice system has picked up the slack. It took an indictment and conviction to stop Christopher Duntsch, also known as Dr. Death, the Dallas neurosurgeon who killed or maimed 33 of his patients a decade ago. The Texas medical board knew about his ineptitude, yet did nothing to stop him.
Far more routine examples of malpractice have also been the subject of criminal indictment, such as the Nashville nurse RaDonda Vaught who was found guilty in 2022 of negligent homicide for a medical error, after the nursing board declined to pursue discipline.
Professionals should be prosecuted for misconduct when it meets the elements of a crime. However, we should not view the criminal justice system as an appropriate substitute for meaningful professional discipline. For one thing, criminal laws do not cover all dangerous professional practices.
For another, prosecutors and judges are inexpert about safe professional practice — the point of licensing is to give professionals a say in who gets to keep their license. Finally, the criminal justice system can be imprecise.
In the cases of Dr. Duntsch and Dr. Ballard, it was too little, too late. And in the case of Ms. Vaught, many have claimed it was the opposite — too draconian.
The professional licensing system needs an overhaul. Self-regulation through state boards has (among other problems) made discipline far too light, slow, and collegial to be safe.
States need to change who sits on professional licensing boards, make them advisory to an accountable government official, or both. Our safety and public health depend on it.
Rebecca Haw Allensworth is a professor at Vanderbilt Law and author of “The Licensing Racket.”
