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Ideas and insights to help health care providers stay informed and profitable in today's challenging health care environment.

Population Health Was Born in Franklin County

by Caroline Smart, CloudView Editor

Welcome back to Population Health(ier), a recurring series featuring athenahealth and The Atlantic’s best storytelling on America’s population health revolution. To catch up on our series, you can find last week’s story here. Today, we explore how the physicians in rural Maine revolutionized the national approach to community health by expanding their staff and enlisting their patients.

More than 15 percent of the 30,000 residents in Franklin County, Maine live below the poverty line. One in five is over the age of 65. With just 17 people per square mile, lack of access to care is pervasive.

Yet a curious phenomenon has been taking place in this corner of western Maine: Franklin County boasts the same, if not better, cardiovascular health than residents living in wealthier, more urban parts of the state.  As the nation grapples with what President Obama has called “the number one killer of American women and men,” this rural community  has emerged as an unlikely leader in the battle for healthy hearts.

With the deck stacked decidedly against it, how did Franklin County become a population-health success story?

A study published earlier this year in the Journal of the American Medicine Association (JAMA), which tracked the last 40 years of population health in Franklin County, discloses several surprising findings. Chief among them is that physicians in the small, rural county embarked on what would become the “first comprehensive community health intervention in the United States (and the second in the world) to report significant reductions of cardiovascular disease risk factors, hospitalizations, deaths, and healthcare costs.”

In the early 1970s, there were only 15 physicians serving the area, many of them nearing retirement. And with one physician for every 1400 residents, the availability of doctors was almost half the national average. Franklin’s physicians were frustrated that, despite their best efforts, many low-income residents were not able to get the quality of care that they needed. Together, they formed a local Rural Health Association, or RHA, a local, community-based, non-profit model of health-care delivery.

The RHA’s first order of business was to expand medical insurance to cover 3,000 previously uninsured people in the county—an increase in coverage of more than 10 percent. The RHA provided training for physician assistants, becoming one of the first places to employ these mid-level clinicians in the country. With the help of 200 volunteer nurses, they began what became a 40-year effort to improve cardiovascular health by focusing first on blood pressure and later on cholesterol, diabetes, and smoking.

In that time, the Franklin community health program almost doubled access to primary care, bringing the patient-physician ratio to 853 to one in 2010. It also reduced hospitalization rates, resulting in some $5 million in health-care savings annually, all while improving the lives of residents who suffer from chronic diseases.

Detailed documentation of patients’ records over the decades—first on paper, eventually computerized—gradually provided the scientific proof that their methods were working.

Decades before “population health” became the buzzword it is today, the Franklin community health model promoted precisely that: expanding the concept of care from what happens at the time of a patient’s visit to a doctor or hospital to a more holistic approach that takes into account not only the individual’s specific needs but also the overall health of the community.

By focusing on small, incremental steps with tangible results, Franklin County’s health system has set itself apart.  Now, America seems to be catching up.

Over the last decade, the health care community has started to recognize what Franklin County began learning from experience more than forty years ago—that paying attention to the health of the community as a whole can pay dividends for individual patients, too. Since the term “population health” was coined in 2003 with a deceptively simple definition—“the health outcome of a group of individuals, including the distribution of such outcomes within the group”—it has emerged as a new paradigm for health care.

Before population health can go mainstream, however, there’s a critical hurdle to overcome. Most doctors and hospitals are currently paid for each service they perform. When communities become healthier and require fewer costly emergency services, doctors and hospitals earn less.

Franklin County has experienced first-hand the problematic nature of health-care reimbursements. The proven success of its cardiovascular programs has become a kind of double-edged sword: Because of the county’s exceptional preventive-care delivery and the way in which its current payment system is structured, hospitals caring for Franklin County residents take in $5 million less a year than they used to.

The structure of reimbursements is beginning to change, if slowly.  The Affordable Care Act has applied pressure to the longstanding fee-for-service payment method in favor of value-based care, which rewards providers that can keep costs down while meeting strict benchmarks for the quality of care they deliver—an effort to prevent rationing of health-care spending.  Under the law, Medicare is introducing new types of “alternative payments models.” Physicians with more than 5,000 patients can now form an “accountable-care organization” (ACO), the most popular of these models. ACOs can be rewarded up to 60 percent of the costs they manage to save. At least 744 health organizations have consolidated into ACOs since 2011, according to Kaiser Health News statistics, and they now serve more than 20 million Americans. Collectively, they’ve saved more than $400 million dollars in health care spending.

While these kinds of alternative payment models are gaining momentum, they haven’t yet reached Franklin County. Despite continuing losses, the community’s hospitals have stood firmly behind the county’s population-health initiatives.

According to the JAMA study, “The Franklin County experience indicates that [community health] problems can be overcome and suggest that demonstrated improvements in community health can be replicated elsewhere, including in urban areas.”  The study’s authors concluded: “The [Franklin County] experience deserves consideration as a model for other communities to emulate, adapt, and implement.”  The only question is, how quickly will new reimbursement models catch up as their reward?

Tune next week to learn if a healthy mind can lead to healthier bodies in rural America.


To experience an interactive feature along with access to the full Population Healthier series, visit The Atlantic.



Caroline Smart is a Senior PR Associate and CloudView Editor.

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