Northern Light Maine Coast Hospital shown in November 2018. Credit: Bill Trotter

Visits to the hospital are never fun, and they’re rarely straightforward.

But for some residents of eastern and central Maine who have a medical emergency — a broken leg, an allergic reaction, chest pain — seeking help is about to get more complicated.

It could cost more, too.

Starting early this year, many doctors who staff hospitals in Blue Hill, Ellsworth, Pittsfield and Waterville will no longer work for the hospitals themselves or its parent organization, Northern Light Health. Instead, they’ll work for a company based more than 1,000 miles away. TeamHealth, a physician staffing firm headquartered in Knoxville, Tennessee, has signed a contract with Northern Light to employ the emergency medicine and hospitalist doctors in those four hospitals.

That means patients who see those doctors would get a separate bill from TeamHealth, in addition to any others from Northern Light.

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It also means patients who have confirmed that their local hospital accepts their insurance could be in for a shock: It’s not a given that TeamHealth will accept that insurance, too. If it doesn’t, patients could be stuck with a hefty bill.

Northern Light administrators say the new partnership will help the system — formerly called Eastern Maine Healthcare Systems — deliver stronger, more efficient hospital care. It comes as the organization has struggled to fill open positions at those small, regional health centers in recent years.

Yet at a time when Americans have grown increasingly wary of the steep costs and mysterious origins of medical bills, TeamHealth’s arrival could also put new, upward pressure on the price Mainers pay for a trip to the hospital.

In particular, if TeamHealth refuses to accept the prices offered by Maine patients’ health insurers, patients could be exposed to costly out-of-network bills.

A recent study from Yale University found that when TeamHealth and one of its competitors entered hospital emergency rooms between 2011 and 2015, a greater share of patients with health insurance accepted by the hospital ended up seeing physicians who were outside their insurance network.

The resulting bill from an unknown, out-of-network contractor could be more than double what the insurer was willing to pay, according to the Yale research. When that happens, patients may then be asked to cover the difference, and the so-called “surprise” or “balance” bill can reach hundreds or thousands of dollars.

Alternatively, if insurers agree to the steeper bill, they can pass that price on to patients through higher premiums.

While Northern Light administrators say that any insurance patients have used in the past should still work under the new partnership, a TeamHealth spokeswoman said the company may send out-of-network bills to Maine patients.

In 2014, about 20 percent of inpatient admissions and 14 percent of outpatient visits to ERs in the U.S. led to out-of-network bills, according to a report by the Federal Trade Commission. A recent poll by the Kaiser Family Foundation found four in 10 Americans said they’d received a surprisingly large invoice for medical care in the last year.

Members of Congress, meanwhile, have started considering solutions to the problem. In Maine, a law that took effect at the start of 2018 aims to protect patients from surprise, out-of-network bills. TeamHealth’s entrance into the four Northern Light hospitals could test the strength of the new law.

[New law seeks to protect Mainers from surprise medical bills]

Some members of the health care industry have said out-of-network billing isn’t common in Maine, but it has been reported here. Ann Woloson, executive director of the Augusta-based advocacy group Consumers for Affordable Health Care, has heard from patients who thought a hospital and surgeon would take their insurance, for example, then were billed by an out-of-network anesthesiologist.

Besides the questions about TeamHealth’s billing, it’s still unclear what specific changes are coming to the staffing of the four hospitals under the for-profit contractor: Northern Light Blue Hill Hospital, Northern Light Maine Coast Hospital in Ellsworth, Northern Light Sebasticook Valley Hospital in Pittsfield and Northern Light Inland Hospital in Waterville.

Credit: Nick Sambides Jr.

The TeamHealth spokeswoman and Northern Light administrators didn’t respond to specific questions about how many clinicians will work at those hospitals going forward, but both emphasized their focus on improving quality outcomes. However, one doctor who said he was offered a contract to work at one of those hospitals under TeamHealth questioned whether there will be adequate emergency room staffing.

Woloson knows little about TeamHealth and hopes the new arrangement will allow quality physicians to keep working in rural places like Blue Hill and Pittsfield, where it can be hard to attract well-trained professionals. Yet she questioned how Maine patients will be asked to pay for the company’s services.

“I think Northern Light is really trying to manage its entire system in a way that will not only make it competitive, but also meet the needs of people living in those rural areas,” Woloson said. “This might be a way to do that.”

Still, she said, “I do have concerns about this. How are people going to know whether the TeamHealth person is in-network and whether they will be billed for services? Maine does have some protections, but they’re not necessarily foolproof.”


Founded in 1979, TeamHealth has grown into one of the country’s largest physician staffing companies. It has more than 12,000 workers in a range of medical fields, including hospital and emergency medicine, primary care and anesthesia. In 2016, the private equity firm Blackstone acquired it for $6.1 billion, according to Reuters.

Under the new contract, it will become the employer of two types of providers at the four hospitals in Blue Hill, Ellsworth, Pittsfield and Waterville: ER clinicians and hospitalists. The latter are doctors who provide a mix of inpatient services. The new staffing arrangements will start to take effect around the beginning of February, according to Northern Light, and TeamHealth is already advertising physician openings at the Maine hospitals.

Credit: Nick Sambides Jr.

TeamHealth will also start working with other hospitals in the $1.7 billion network, including its flagship campus, Northern Light Eastern Maine Medical Center in Bangor. It may submit a proposal to staff three other Northern Light hospitals in Portland, Greenville and Presque Isle in the coming months.

[Saving ailing hospitals created fiscal strain for Eastern Maine Healthcare]

Northern Light says the new arrangement is a win-win. Administrators think the practices TeamHealth has developed over decades of operation will help trim costs, improve patient care and give the hospitals more flexibility to fill staff openings, allowing them to keep serving the rural residents who depend on them.

“We don’t know all things, in all areas. Nobody does. So this is an example of a strategic partnership between Northern Light Health and TeamHealth,” Steven Berkowitz, Northern Light’s senior vice president and chief physician executive, said. “This is what they do, and they do it well. They can bring experiences from literally hundreds of emergency departments across the country: what’s worked, what hasn’t worked. So I’m very excited about them taking a very comprehensive look at what we’re doing and what can we do to be even better.”

While Berkowitz said Northern Light providers already deliver strong care, he said TeamHealth has systems for measuring performance that will help it find efficiencies and improve a number of outcomes, such as hospital readmissions and how long patients must wait to be seen.

Another reason Northern Light is pursuing the new arrangement is because it’s had to pay for temporary doctors, known as locum tenens physicians, to fill openings in recent years.

That interim staffing can cost a hospital more than twice as much as full-time employees, given the travel and other expenses they require, but TeamHealth has a nationwide network of doctors it can draw to Maine at less expense and with less hassle, according to Berkowitz.

[Seven doctors resign from small Maine hospital]

At least one of the system’s hospitals, Northern Light Maine Coast Hospital in Ellsworth, has struggled with physician turnover and staffing costs since joining the system in 2015.

Last year, a group of doctors left after the parent organization made controversial changes to their contracts, according to the Ellsworth American. The hospital’s reliance on costly locum tenens doctors has contributed to millions in operating losses over the last few years, its president told the Ellsworth American in December. It projects a $4 million loss this year, after even greater losses in 2016 and 2017.

Out-of-network bills

While the new arrangement may help Northern Light’s bottom line, it remains to be seen whether patients will feel the same way about their own wallets.

When TeamHealth and another physician staffing company, EmCare, entered hospital ERs between 2011 and 2015, their entrances were associated with a jump in out-of-network billing, though the change was more dramatic under EmCare, according to the study published in March 2018 by researchers at Yale University.

Using data provided by an unidentified health insurance company, the researchers found that under EmCare, there was an 81 percent hike in the portion of visits by that insurer’s customers that led to an out-of-network bill, compared with 33 percent under TeamHealth.

The study also found that TeamHealth’s arrival raised the price of emergency care in another way. Several months after the company’s doctors went out-of-network, many of them negotiated to re-enter the insurance network and received in-network rates 68 percent higher than they had received previously, the researchers found.

“This is an example of the firm using a now-credible threat of out-of-network billing to gain bargaining leverage in their negotiations over in-network payments,” the authors wrote.

Credit: James Crawford | TNS

Some consumer advocates and academics have assailed the practice of balance billing, saying it blindsides patients who can’t control which doctors see them in a hospital or know what those private doctors have negotiated with insurance providers, according to past reporting by The New York Times.

For U.S. patients who learn they must pay out-of-network medical bills, the damage can be severe.

Those bills range in price from hundreds of dollars to more than $19,000, according to a 2016 study from Yale University. Using insurance company data, that research found about one in five emergency room visits nationwide led to an out-of-network bill, although the practice didn’t appear to be common in Maine.

“To put it in very, very blunt terms: This is the health equivalent of a carjacking,” Zack Cooper, an assistant professor of health policy and economics at Yale, told The New York Times. He co-authored both the recent study on staffing companies such as TeamHealth and the earlier one on out-of-network billing.

A group representing ER doctors, the American College of Emergency Physicians, pushed back on some of those findings, saying they overstate the risk of balance billing. It argued that insurers are the ones who have failed to offer reasonable in-network rates.

In Maine, patients at the four Northern Light hospitals will soon learn whether it’s a problem here.

A TeamHealth spokeswoman didn’t directly respond to questions about whether the company plans to enter the insurance networks accepted at those hospitals, but she left open the possibility that the company could send out-of-network bills to Maine patients.

TeamHealth works “diligently to negotiate fair market rates with managed care plans and payers before beginning services at any client facility,” the spokeswoman, Natalie Bullock, wrote in an email. “If/when TeamHealth clinicians are out-of-network at a particular hospital and/or facility, we do everything we can to avoid out-of-network payment for the physician services portion of a patient’s bill. When out-of-network payment is unavoidable, we work closely with patients and families to reach amicable payment solutions.”

At Northern Light, Berkowitz said he doesn’t expect any major insurance changes for patients under the new arrangement.

“When they come to our ER or get admitted to our hospital, whatever insurance they have with us, the same things would occur, the same things would” be covered, Berkowitz said. “Now, could there be some unusual insurance arrangement with some insurance company? I guess it could, but the intent is to make this seamless.”

“And I want to know if there is an issue like that,” he added. “Our intent is not to somehow or another pass on more costs to a patient, or something like that.”

Berkowitz said that he was not aware of any terms in TeamHealth’s contract that would prevent the contractor from going out of network, and he doesn’t expect patients to be notified if they’re seeing a doctor not directly employed by Northern Light. He referred most questions about future billing to TeamHealth.

Kevin Lewis, president and CEO of one of Maine’s health insurers, the nonprofit Community Health Options, said in late December that he wasn’t aware of any negotiations the insurer has had with TeamHealth. He said he couldn’t comment on how any negotiations with the company might go.

“We certainly value our partnership with Northern Light and its system of hospitals,” he said. “These are important access points. We certainly look to ensure good access to care.”

In Maine, patients have some protections against the costs that can come from visiting an out-of-network doctor at a facility that otherwise accepts their insurance.

One law that took effect at the start of 2018 requires insurers to pay for non-emergency medical services provided by out-of-network providers if the patient had reason to believe the provider was in network and covered by the insurer. It also mandates that insurance companies in the state offer accurate, online directories of providers in each plan that they update monthly.

That law applies to services provided by hospitalists, one of the types of physicians that will be employed by TeamHealth under its new deal with Northern Light, Judith Watters, a consumer outreach specialist at the Maine Bureau of Insurance, wrote in an email.

Another state law requires that health plans subject to terms in the federal Affordable Care Act pay in-network rates for emergency medical costs even if an out-of-network provider provides those services.

Watters said that Mainers can report any concerns about medical billing or claims to the consumer health care division of the Maine Bureau of Insurance by calling 800-300-5000.

However, even in states that have passed comprehensive laws protecting against balance billing, there are gaps that have allowed the practice to persist, according to a 2017 analysis by the Commonwealth Fund.

Woloson, from Maine Consumers for Affordable Health Care, questioned whether Maine’s laws would ensure that all services provided by TeamHealth physicians are covered if the physicians are outside the accepted insurance networks.

“It’s not clear how expansive the scope of care is that their doctors will be providing in hospitals,” she said. “If this news is out, that TeamHeath has providers out working in hospitals, there could be an argument that if someone is billed by an out-of-network provider, that it might not be considered surprise billing, especially if it happens more than once.”

For-profit care?

While roughly two-thirds of U.S. hospitals have outsourced the staffing of their ERs, according to the recent Yale study, there are few precedents for it in the Pine Tree State, according to Charles Pattavina, an emergency physician at St. Joseph Hospital in Bangor who recently served as that hospital’s medical director and chief of emergency medicine.

Pattavina — a recent president of the Maine Medical Association who has been on the national board of the American College of Emergency Physicians — isn’t aware of any other Maine systems that have outsourced at the level of Northern Light.

Credit: Stock photo

The American College of Emergency Physicians has challenged the view that ER doctors are to blame for out-of-network billing, arguing that patients would fare better if their insurers offered more reasonable rates and more comprehensive provider networks.

Speaking for himself, Pattavina said the recent findings on TeamHealth by the Yale researchers were sound, but he disagreed with the premise that there was something unseemly about the company’s reported practice of threatening out-of-network coverage to secure higher in-network rates.

“That’s just business,” he said. “They can play hard ball with the insurance company. You would hope they play hard ball together.”

However, Pattavina raised other concerns about the entry of a large, outsourcing company into Maine’s ERs. For one thing, he said that a hospital has less control over the quality of its physicians when a contractor takes over.

Pattavina knows talented physicians who have worked in Northern Light hospitals. He also knows good doctors who have worked for TeamHealth and said that in the best cases, staffing companies can bring well trained clinicians to hospitals that need them. The danger, he said, is that existing physicians may refuse to work for the company and be replaced by less qualified providers.

At Northern Light, Berkowitz disagreed with the notion that TeamHealth providers could be less qualified and said they all will have to meet the same standards Northern Light sets for its own staff.

“They have very high credentialing. They have very high standards, and I see nothing but the top quality ER docs and hospitalist docs,” he said. “That’s totally unfounded in anything that I’ve experienced knowing TeamHealth for many years. An organization like TeamHealth has a very extensive credentialing process, as does Northern Light Health. They’re both excellent.”

TeamHealth had a similar response. “All clinicians placed by TeamHealth in the hospital are subject to rigorous screening and credentialing guidelines established by the hospitals in conjunction with TeamHealth,” spokeswoman Bullock wrote in an email.

Pattavina was also skeptical that TeamHealth could find efficiencies across Northern Light without cutting services or raising prices.

Northern Light is classified as a nonprofit organization. But Pattavina noted that as a for-profit company owned by the investment firm Blackstone, TeamHealth is likely trying find a buck somewhere in the deal. The ways it could do that, he said, include cutting positions, paying lower wages or increasing billing, either directly from patients or indirectly from insurers.

“They wouldn’t be in it if they didn’t think they were going to make money,” Pattavina said. “It’s got to come from somewhere, because at the end of the day, Blackstone expects to make money.”

Asked how the company’s profit motive could affect Maine hospital care, Bullock responded, “TeamHealth’s number one priority is patient safety and delivering high-quality care to patients and families.” The company didn’t make any representatives available for an interview.

Credit: David Goldman | AP

Staffing levels

Representatives from TeamHealth and Northern Light didn’t respond to specific questions about how staffing or employment contracts will change under the new partnership. But Berkowitz said staffing will be one of the factors TeamHealth considers when it’s looking for efficiencies.

“Do we have enough doctors, nurses?” he said, as an example of a question he hopes TeamHealth can answer. “Could we have too many doctors? What’s the best way to do that? So we want to rely on them for national models for logistics. … It’s not less care. That’s just not an option. But efficiencies are made by throughput and the ability to make time better spent.”

Some physicians who now work for Northern Light declined to speak publicly about TeamHealth’s plans.

But a semi-retired ER doctor who used to work at what’s now Northern Light Inland Hospital in Waterville said he disagrees with a staffing change that could be near.

Over a career in family and emergency medicine, John Garofalo, 64, of Belgrade has worked at several Maine hospitals. From early 2016 to late 2017, he said he worked full-time in the emergency department of what was then Inland Hospital, before taking another job at St. Joseph Hospital in Bangor.

Although Garofalo enjoyed working at Inland and praised his colleagues there, he couldn’t agree on a new contract with the parent organization that’s now Northern Light. After tiring of the commute to Bangor, though, he signed a new contract to return to Inland on a per diem basis, he said.

Before Garofalo could start, his hiring was put on hold and he was offered a new contract to work for TeamHealth, he said.

However, he refused to sign it because he didn’t agree with a stipulated change in ER staffing. A physician would still be stationed there at all hours of the day, but TeamHealth was proposing to eliminate a second clinical worker — usually a nurse practitioner or physician assistant — who also staffed the emergency department from around 10 a.m. to 8 p.m., according to Garofalo.

While Garofalo doesn’t know much about the quality of TeamHealth’s offerings, he thought the arrangement could prove lacking if the emergency department was inundated. If a doctor was tied up with something serious, he said, the lack of a second worker could force other patients to wait for care.

“The quality of care at Inland is very good. What I’m saying is, this circumstance could lead to a potential for compromise of that,” he said, noting that he was just sharing his personal opinion and hadn’t heard of any actual problems.

“Possibly you may have a patient who is critically ill and you can’t leave the bedside. Does that happen every day? No, but when it does happen, it can lead to real problems in terms of providing care in a timely manner. … I’m not saying I think anything bad has happened, but the potential for it goes up.”

Asked about Garofalo’s concern, a spokeswoman for Northern Light, Karen Cashman, wrote in an email that the organization doesn’t share specific staffing numbers.

Individual “hospitals are staffed based upon historical data with a back-up plan always in place for unforeseen or emergency situations,” she wrote. “We remain comfortable that TeamHealth, as a nationally recognized outcomes-based provider with a demonstrated track record, has developed an appropriate model that will serve our hospitals well.”

Bullock, the TeamHealth spokeswoman, wrote in an email that the company couldn’t comment on specific employment contracts.