Stitching a Safety Net in Uncertain Times - North Carolina Health News
By Taylor Sisk
Phillip Stover, MD, reckons that U.S. Highway 56 divides Franklin County in more ways than one.
The road passes through Louisburg, the county seat, a town of about 3,500 where Stover practices family medicine and pain management. To the south are modest bedroom communities, home to a workforce that commutes 30 to 45 minutes each day into Raleigh.
To the north lies farmland – grain, nursery and greenhouse crops, tobacco, hay – and sparsely populated two-lane roads. As regards access to healthcare services there, Stover said, “it’s the Third World.”
Stover, a Pennsylvania native, arrived in Franklin County in 1983 having received a National Health Service Corps scholarship and thus owing the government three years in a health professional shortage area. He and his wife, Judy, bought the house on North Main Street in which they raised their family and remain.
Franklin County ranks 54th of North Carolina’s 100 counties in health outcomes and 58th in health factors (health behaviors, clinical care, social and economic factors, physical environment). But, Stover argues, those numbers mask a disparity.
It used to take folks in the northeastern corner of the county – in Centerville or Wood, for example – about 15 to 20 minutes to drive down to Franklin Medical Center in Louisburg.
Then, in October 2015, Winston-Salem-based Novant Health announced it was closing the hospital, citing a significant decline in usage over the past several years. It’s since been announced that Duke LifePoint will open, probably sometime this year, an emergency department and rooms for mental health patients in the former hospital building.
Stover despairs for the healthcare of those most in need. He acknowledges that the reopened ED will be welcomed. But more routine care, and care for chronic conditions, will remain an issue, he said. According to data from the North Carolina Institute of Medicine, in 2014 there were 1.9 primary care physicians and 1.1 dentists for every 10,000 residents of Franklin County. There were no psychiatrists. The closing of the hospital only worsened that predicament.
Chronic conditions tend to be more prevalent in rural communities. A recent report by the National Advisory Committee on Rural Health and Human Services indicates that life expectancy in rural American communities is consistently lower than in urban areas. And even distances of a few dozen miles can make a difference, one that county-level data might conceal.
For example: Life expectancy in Franklin County is 77.7 years. In Wake County, where more than half of Franklin County residents commute to work and receive their healthcare, it’s 81.6. But in rural Halifax County – whose southern residents are neighbors with Franklin’s northern ones – it’s 74.9.
Yet another source of angst for Stover is the future of Medicaid. Healthcare providers in rural communities are more dependent on Medicaid dollars than their urban counterparts. But North Carolina chose not to expand Medicaid. And, regardless, under the Trump administration, the future of the program is uncertain.
Folks north of that 56 divide, Stover said, are in dire need of more accessible, affordable healthcare.
In 2004, Stover helped launch a clinic in Louisburg. Now called the Franklin County Partners in Health, the focus of the clinic is on chronic illnesses – diabetes, hypertension, coronary artery disease – which are more common in rural communities.
“These are lifestyle diseases, to a certain extent,” Stover said, “and we’ve come to learn that lifestyle is very often dictated by people’s economic status. It’s one thing to tell people to eat good food, but it’s another for them to afford it.
“So we decided that was where we could make the most impact and change people’s lives. Take hypertension, for example. For a lot of patients, for less than $10 a month we can treat their blood pressure, and very possibly prevent a stroke.”
The clinic charges $5 for an initial visit and $3 for subsequent ones, “on the contingency,” Stover said, “that if someone can’t afford it we’re going to waive it.”
For several years, the clinic received grant funding from the state for a joint initiative with the county health department, which allowed it to employ a staff of five or six. The clinic also experimented with expanded-role nursing. But Franklin County was subsequently reclassified by the N.C. Department of Commerce as being among the state’s more prosperous counties (it has since been downgraded), and the clinic consequently lost its grant.
“We’re struggling to keep the doors open,” Stover said.
Franklin County does have a federally qualified health center, Advance Community Health. As an FQHC, it receives enhanced reimbursement from the Centers for Medicaid and Medicare Services. But prospects for the continuance of that revenue – dollars already stretched thin – hang in balance.
‘Big gray cloud’
Stover’s vision of the future of healthcare for northern Franklin County is obscured by “a big gray cloud.”
He’s “terrified” for “this 20 percent of our population that just has no access right now” – not enough money and/or no transportation. “These folks are dying. They’re suffering needlessly from diseases that we have treatments for – who probably, if we did it right, would cost society less” than what it takes to treat chronic conditions that could have been avoided or at least mitigated.
“And I don’t see those folks getting services anytime in my lifetime the way they should.”
Franklin County has a new public health director, Scott LaVigne, and he and Stover plan to discuss how they might move forward together.
LaVigne embraces the concept of a clinic focused on chronic illness.
“You can be penny wise, pound foolish,” he said. “If left unchecked, people will show up [in the ER] in dire straights, requiring huge amounts of intervention, generating thousands of dollars of bad debt per episode of care that hospitals won’t be able to recover. It just perpetuates an over-reliance on emergency care and it perpetuates using other resources to cover it.”
If local and state government dollars are needed to provide care for everyone, LaVigne’s on board. But he has no illusions about how much can be done without sufficient investment from the feds.
Stover has proposed to the county a three-year plan for helping fund the Partners in Health clinic. But the plan is contingent on the future of Medicaid. To stay afloat, he’ll need that reimbursement for a substantial percentage of his patients.
“I’m very concerned,” he said of the county’s neediest. “I don’t see an out for them anytime soon.”