Rural Maine County Pioneers Population Health

Health improvements in sparsely populated Franklin county are no fluke. Forty years of data illustrates that population health works, and that just about everybody can do it with resources they already have.

All the talk around population health makes it sounds like a new concept even though it's been around for nearly half a century.

One pioneer movement for population health in the United States began in Franklin County Maine, a sparsely populated, rural, inland expanse north of Portland. Many of the county's 30,000 residents are older, sicker, and poorer than the overall population of the state.

Yet, when it comes to certain conditions, particularly cardiovascular health, the residents of Franklin County enjoy the same or better health status than their fellow Mainers in counties with younger, wealthier populations.

This is no fluke. Rather, it is the payoff from decades of community health outreach. In the late 1960s, physicians in the county seat of Farmington joined with the hospital and community leaders to improve and coordinate care for the county's poor.

"It started by recognizing that there weren't very many physicians in the county, that they were all getting older and that there were virtually no specialists," says Roderick E. Prior, MD, a semi-retired primary care physician who has spent the last 38 years working with the county's population health effort.

"This was all before my time," Prior told me. "This was the time of the Great Society in the 1960s. The Office of Economic Opportunity had been started and they were looking at healthcare. They encouraged those folks to think bigger."

Initially, the federal government provided funding to create comprehensive health and dental care for 3,000 people in the county. "That was 15% of the population of the county," Prior says.

"All of a sudden our uninsured rates went down. Access to care became much more available. The other thing that happened was some real interest in outreach. Organizations started some rural health clinics which eventually became federal qualified health centers. We started using mid-level nurses. We were one of the first training grounds for the physician assistant profession."

Prior says the pioneering physicians in Franklin County understood that they were not practicing medicine in a vacuum, and that they needed to work with government, schools, and other community organizations to coordinate care. They worked with the University of Maine at Farmington to create a training program for community outreach workers.  

"They were thinking about things like transportation—[whether] people could travel to get their healthcare," Prior says. "Traditionally, if the patient doesn't show up the doctor says, 'I can't treat you if I you don't come in,' without recognizing that most people can't come for whatever reason; the car is broken down or they don't have gas or the employer says they have to work, or if the kids are sick."

"But it was an organized community-based effort that started looking at where the problems were and went beyond just providing a doctor and medicine to reaching out, finding people who had health problems, and then getting involved with them, monitoring them," Prior says.

"When I use the word 'community,' I mean that people need to identify their community, which means the people for whom you and your colleagues are willing to take responsibility for their health."

40 Years of Results
Over the decades, the funding has ebbed and flowed, but the program has endured and transcended generations of patients and providers.

To get an idea of the effect of the care coordination, Prior and his colleagues examined the data around 40 years of work to improve cardiovascular health in Franklin County. The results were published this month in the Journal of the American Medical Association.

Before the population health efforts began, Franklin County had higher death rates for heart attack and stroke than the statewide average. Once the population health efforts began, however, Franklin County was the only county in the state with consistently lower-than-expected mortality rates for heart disease and stroke.

The county has also seen a steady uptick in smoking cessation and cholesterol control. Researchers estimate that the improved health of the population has saved about $70 million through reduced hospitalizations from 1994 to 2006.

A Large Caveat
That bit of good news comes with a large caveat that explains why population health has yet to catch on in a fee-for-service world.

"There is nobody in Franklin County who is clearly make money from doing this," Prior says. "The savings are going to the insurers. It's Medicaid and Medicare. And, if you look at the way private insurance companies price their products, they don't look at the mortality and hospitalization rates of Franklin County and give all the employers a cost break."

That is a topic for another day.

For now, the lesson from Franklin County is that population health works, and that just about everybody can do it with resources they already have.

Prior says "it's easy" to identify the health risks in any community down to the county level by using publicly available data found on the Centers for Disease Control and Prevention website. At the risk of oversimplifying, identify the healthcare needs of the people you serve, and then find a way to deliver the care once that need is identified. If you can demonstrate the need, the community support will follow.

Looking back on his own nearly 40 years of public service, Prior says he's proud to have played a role in the work of Franklin County's pioneering physicians.

"I wanted to practice medicine and make a difference. I think we have proven to ourselves that we've made a difference," he says. "We wanted to tell our story because we think it's not a bad model for people to think about [as they think about] what they might do… in their own communities."