The emergency department at Northern Light Maine Coast Hospital in Ellsworth is one of four that will be staffed with providers working for a private firm based in Tennessee beginning in February. The change also includes Northern Light hospitals in Blue Hill, Pittsfield and Waterville. ELLSWORTH AMERICAN PHOTO BY CYNDI WOOD

Northern Light outsources ER, in-patient providers

ELLSWORTH — Beginning in February, the doctor who treats you in Ellsworth or Blue Hill may actually work for a private for-profit firm 1,100 miles away.

Northern Light Health has contracted with Knoxville, Tenn.-based TeamHealth to employ emergency medicine and hospitalist providers (those who care for in-patients) at four of its hospitals, including Northern Light Maine Coast in Ellsworth and Northern Light Blue Hill Hospital. The move was made in part to address staffing issues.

“Providing quality patient care is our top priority at Northern Light Maine Coast Hospital and Northern Light Blue Hill Hospital,” said John Ronan, president of the two hospitals, in an emailed statement. “Nationwide, and here in Maine, it’s been a challenge to attract physicians to rural hospitals to fill vacant positions in emergency medicine and hospitalist medicine.

“TeamHealth, is a highly regarded national staffing firm with considerable resources and expertise to help retain and recruit physicians and reduce the costly alternative of hiring locums.”

Patients who are treated by TeamHealth providers may receive separate bills, one from the hospital and another from the provider.

Northern Light announced that it had contracted with TeamHealth in October.

In a move aimed at standardizing care, TeamHealth also will assume “clinical oversight responsibilities” at all hospitals in the Northern Light collaborative. (Physicians at hospitals other than Blue Hill, Ellsworth, Northern Light Inland Hospital and Northern Light Sebasticook Valley Hospital will continue to be employed by Northern Light Health.)

“We believe this relationship will help us further increase quality and patient satisfaction while helping people get out of the hospital faster and decrease readmissions,” Ronan said.

Whose doctors?

“I look at it as doing three things,” said Steven Berkowitz, Northern Light’s senior vice president and chief physician executive, of the move to physician staffing with TeamHealth. “Improving our quality, improving our access and improving our bottom line.”

To his knowledge, Berkowitz said, all providers at the four Northern Light hospitals were offered contracts with TeamHealth. Those who choose to stay, he said, “will be employees of TeamHealth. TeamHealth will collect their professional fees; pay their salaries, benefits, malpractice insurance.”

“The intent is to keep all of our providers,” said Berkowitz, although he acknowledged that some have opted not to stay. “That’s common whenever there’s a change.”

Berkowitz said TeamHealth has a retention rate of around 90 percent when it comes into a hospital. (Providers include doctors, nurses and physician assistants, among other health care workers.)

TeamHealth and Northern Light Health will “work together in the areas of credentialing,” Berkowitz said.

TeamHealth will have hiring and firing power, Berkowitz said, but added that if an issue came up with an employee “I can assure you we will work together.”

Maine Coast has been dogged by staff turnover in recent years. At least four physicians left the emergency department after the hospital was acquired by Northern Light Health (then Eastern Maine Healthcare Systems), according to previous reporting in The American.

The hospital moved its emergency department to a “collaborative” staffing model in 2017, sharing physicians between several hospitals, in part to reduce reliance on expensive locum tenens, physicians or specialists who work on a short-term or long-term basis.

This model will be “phased out” as TeamHealth takes over, said Kelley Columber, Northern Light spokeswoman, in an email.

Asked whether there would be changes in staffing levels at the hospitals, Berkowitz replied that “there may be some differences in staffing ratios. I believe there will be some improvement in staffing because it’s more efficient,” but said “We’re not anticipating a major change.”

Outsourcing the ER

Physician staffing firms have become big business in recent years as hospitals, especially in rural areas, struggle to compete for a limited pool of providers.

This can mean that physicians live in another city or state and travel to a rural hospital for their shifts.

This move by Northern Light Health, said Gordon Smith, executive director of the Maine Hospital Association, “is simply Maine seeing the same trends around the country in terms of the consolidation in the physician services industry.”

“It’s largely happening because health care is so damn expensive,” Smith continued. “To provide that service in your community now… it’s really hard.”

(Maine’s largest hospital organization, MaineHealth, does not use “any of those large physician staffing organizations,” a spokeswoman for the group said in an email.)

Emergency departments were once staffed on an ad-hoc basis, wrote Yale researchers in a 2018 paper looking into out-of-network billing at hospitals where staffing has been outsourced. But the use of such departments has grown dramatically in the past decades, to the point where around half of patients admitted to the hospital now come in through the emergency department.

“Because EDs have become a major source of patients, hospitals now want to keep their EDs open at all hours and run them efficiently,” authors write. “As a result, there has been a marked increase in the outsourcing of management of hospital EDs.”

“It’s actually the typical way that emergency departments are staffed in the rest of the country,” said Jay Mullen, president of BlueWater Emergency Partners, a medical staffing company based in Brunswick.

“The typical places that are outsourced in Maine are radiology groups, hospitalist groups, pathology, anesthesiology and orthopedics,” Mullen said.

Surprise billing

Started in 1979, TeamHealth has capitalized on the increased use of medical staffing firms to the tune of billions.

The group is one of the largest such companies in the country, employing more than 12,000 providers in numerous specialties, and was acquired in 2016 by private equity firm Blackstone for $6.1 billion.

Deutsche Bank estimated in 2013 that TeamHealth and staffing organization EmCare make up 30 percent of the provider outsourcing market.

Although hospital administrators say the switch to TeamHealth will improve the quality of care, save the hospitals money and potentially decrease waiting times, it could also cost patients more.

With the growth of outsourced staffing, it is now not uncommon for patients to receive separate bills from the hospital and from the physician who treated them, and providers working for TeamHealth may not accept the same insurance the hospital does.

If this happens, patients could be stuck paying out-of-network costs for care or covering the difference between what their insurance will pay and what the out-of-network provider is charging (known as a “surprise” or “balance” bill).

At some hospitals, this has meant skyrocketing costs. In the Yale study looking at TeamHealth and EmCare, the nation’s two largest staffing organizations, researchers found that after the hospitals contracted to staff their emergency departments with outside providers, patients were more likely to be charged for out-of-network services.

After several months billing out-of-network, TeamHealth renegotiated to have its providers in network, wrote researchers, but used “a now credible threat of out-of-network billing to gain bargaining leverage in their negotiations over in-network payments.”

Using this leverage, TeamHealth was able to secure payment rates for in-network services that were 68 percent higher than previous in-network rates.

Berkowitz said administrators at Northern Light are working to make sure that doesn’t happen.

“Certainly all of the major carriers we are working together to have contracts with,” Berkowitz said.

Asked whether he worried about TeamHealth using threats to gain bargaining leverage, Berkowitz said: “I do not see that as a possibility. It’s in everybody’s best interest to make sure that all parties are contracted.

“If one resident has one particular insurance company it may be that that is theoretically possible” for there to be out-of-network billing, said Berkowitz, but “the intent is we want to include everybody.”

BlueWater President Mullen said he couldn’t speak to Northern Light’s negotiations with TeamHealth, but said that for patients whose hospital is moving to such a model “The biggest thing would be to find out ahead of time. Do the emergency physicians participate in the same insurances?”

States limit surprise billing

Some states, including Maine, have moved to protect patients from unexpected out-of-network charges. Earlier this year, a law went into effect intended to protect patients from unexpected costs in instances where the patient “did not knowingly elect to obtain such services.”

The law is aimed at protecting patients from balance billing for the services of an out-of-network hospitalist, for instance, but it does not apply to emergency services.

“This bill went through an extensive process of stakeholder engagement, a public hearing,” said Smith, who worked on the legislation. “To slap that obligation on every emergency room was unfair given that it’s really not been a problem in Maine.”

There are also federal stipulations intended to protect those who get their insurance through government exchanges under the Affordable Care Act. But these protections may not extend to balance billing, said BlueWater President Mullen.

“I think we’re going to find out pretty quickly” if Maine’s laws are strong enough to protect patients, Mullen said. “I think that TeamHealth has so much leverage that they likely will be able to exert a lot of pressure on the laws that are in the books.”

Kate Cough

Kate Cough

Kate covers the city of Ellsworth, including the Ellsworth School Department and the city police beat, as well as the towns of Amherst, Aurora, Eastbrook, Great Pond, Mariaville, Osborn, Otis and Waltham. She lives in Southwest Harbor and welcomes story tips and ideas. She can be reached at [email protected]

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