primary care capacity shortage & the potential impact of hospital closures

8/14/2019 Primary Care Capacity Shortage & the Potential Impact of Hospital Closures

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A PRIMARY CARE CAPACITY SHORTAGE IN NEW YORK CITY

&

THE POTENTIAL IMPACT OF HOSPITAL CLOSURES

A REPORT PREPARED BY

THE PRIMARY CARE DEVELOPMENT CORPORATION &

THE NEW YORK CITY HEALTH AND HOSPITALS CORPORATION

SEPTEMBER 2006

Nancy Lager, MPH, MSUP

Dona Green, MBA

Victor Kim

Deborah Zahn, MPH


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A Primary Care Capacity Shortage in New York

& the Potential Impact of Hospital Clos

ACKNOWLEDGEMENS

We wish to thank the ollowing individuals or their insight and assistance in preparing this analysis:

Ronda Kotelchuck, MRP, Executive Director, Primary Care Development Corporation

Sta rom the Center or Health Workorce Studies, State University at Albany, specically, JeanMoore, MSN, Director; Robert Martiniano, MPA, MPH, Project Director; and Maria Kouznetsova,MPH, PhD, Program Research Specialist

John C. Billings, JD, Associate Proessor o Health Policy and Public Service, Robert F. WagnerGraduate School o Public Service at New York University, and Director, Center or Health andPublic Service Research

For additional copies o this report or or more inormation, please contact Deborah Zahn at212-437-3942 or [email protected].


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A Primary Care Capacity Shortage in New York City

& the Potential Impact of Hospital Closures

Table of Contents

ACKNOWLEDGEMENTS

EXECUTIVE SUMMARY 1

INTRODUCTION 4

FINDINGS 5

RECOMMENDATIONS 13

METHODOLOGY & DATA SOURCES 15

APPENDICES

TABLES

1 Primary Care Physicians Available to All and to Low-Income Only New Yorkers 5

2 NYC Emergency Room Utilization by Borough, 2005 7

MAPS

1 NYC Primary Care Physician Shortage Areas for Medicaid-Enrolled Residents 6

2 NYC ACS Admission Rates for 0-17 Population 8

3 NYC ACS Admission Rates for 18-64 Population 9

4 NYC Primary Care Physician Shortage Areas If No Hospital-Based Physicians Available 12

APPENDICES

A Primary Care Physician Shortage Areas for Medicaid-Enrolled Residents, by Borough 17

Primary Care Physician Shortage Areas for Medicaid-Enrolled Residents, by Zip Code 18

B Primary Care Physician Shortage Areas for Medicaid-Enrolled Residents,Travel Adjusted 19

C Hospitals in NYC 20

D Comparison of High ACS Admission Areas and Designated HPSAs in NYC 21


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Executive SummaryPurpose

New York State currently is engaged in a long-await-

ed policy discussion about the size and shape o itshealth care system. Tis is particularly meaningulnow because resources are or will be available to sup-port a restructuring o that system. A primary cata-lyst o this eort is the Commission on Health CareFacilities in the 21st Century. Te Commissionsnal report, due at the end o 2006, will includespecic recommendations on hospital and long-termcare acility restructuring and closures. Tese rec-ommendationsand a new Governors response tothemwill have signicant implications orNew York City.

A major gap in the Commissions charge is primarycare, which represents the majority o community-based health services beore and ater hospitalization.o that end, the Primary Care Development Corpo-ration (PCDC) and the New York City Health andHospitals Corporation (HHC) conducted an analy-sis o primary care physician availability and popula-tion vulnerability in New York City. Te purpose o

this analysis was to:

Assess primary care physician capacity avail-able to New York Citys residents, particularlylow-income New Yorkers;

Determine how primary care physician avail-ability may be aected by hospital restructur-ing/closures; and

Identiy considerations that policymakers

should take into account to maintain access tocare and to ensure that the health o low-in-come or vulnerable New Yorkers is not com-promised when making hospital restructuring/closure decisions.

A Caveat

While a more detailed population-specic assess-

ment is needed to make planning decisions or anyparticular community, this report is an importantstarting point in assessing the level o primary carephysician capacity currently needed in New YorkCity as well as capacity that may disappear as a resulto hospital closures. Low-income New Yorkers,which includes persons receiving public insurance,such as Medicaid; the uninsured; and underinsuredare highly reliant on hospitals or primary care. Weused Medicaid enrollees as a proxy or low-incomeresidents because the data available on a zip codelevel or physicians allowed us to extrapolate thosephysicians available to Medicaid patients but notthe uninsured or underinsured. Tis results in anundercount o low-income residents since this proxyexcludes the number o uninsured or underinsuredlow-income New Yorkers, which is signicant as onein our non-elderly residents o New York City1.7million personswere uninsured in 2002-2003.1

While this report ocuses on physician capacity, we

recognize that mid-level providers (such as nursepractitioners) and physician residents, who workprimarily in hospital settings, are essential contribu-tors to primary care capacity or low-income NewYorkers. Tese providers were not included in thisreport because data are not readily available at thezip code and payor levels. Further analysis needs tobe done to provide a more robust depiction o avail-able capacity and existing shortages.

Additionally, this report does not address a number

o other access issues. Physician supply is only one omany contributing actors when considering accessto health care. Health insurance coverage, languageand cultural access, quality o care, and institu-tional and operational eectiveness also are criticalto ensuring access to health care. Tus, increasingphysician capacity alone will not eliminate all ac-cess to care issues. For example, many uninsured


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New Yorkers are likely to still experience barriers toaccessing care and disparities compared to insuredNew Yorkers.

Findings

Te major nding o this analysis is that low-incomeNew Yorkers currently rely heavily on hospitals orprimary care. Tus, hospital closures could elimi-nate a major source o primary care and exacerbateexisting shortages, particularly those experiencedby low-income New Yorkers. Tis would worsencommunity health status, heighten disparities, andincrease costly but avoidable emergency room andinpatient utilization, both o which are indicative o

an inadequate primary care system. Specically,we ound that:

1. More than hal o New York City communi-ties have a signifcant shortage o primarycare physicians serving low-income NewYorkers.2 Although 39% o New York Citysresidents are enrolled in Medicaid, theyhave access to just 25% o the primary carephysicians based in the City.

2. Unnecessary emergency room use andavoidable hospitalizations are particularlyhigh in low-income communities.

3. Tirty-two percent o the Citys primarycare physicians available to low-incomeresidents528 o 1,665 FEsare basedin hospitals, making access to care or low-income New Yorkers highly vulnerable tohospital closures.3

4. Hospital restructurings/closures will in-crease the stress on an already strainedprimary care system.

5. New York Citys ambulatory care system is

signifcantly underdeveloped compared toits inpatient system.

6. Ample research shows that, while preserv-ing and enhancing primary care capacityrequires up-ront investment, it produceshealth system savings and improved health

outcomes over the mid- and long-term.Recommendations

Based on the ndings in this analysis, we recom-mend the ollowing:

Recommendation 1: New York State policymakersmust address current underlying shortages in theavailability o primary care resources.

Although 39% o New York Citys residents are en-rolled in Medicaid, they have access to just 25% othe primary care physicians based in the City. NewYork City needs to eliminate primary care short-ages or Medicaid-enrolled residents to meet Federalcapacity benchmarks.4

Recommendation 2: At minimum, hospital re-structurings/closures should not undo the expan-sion o the primary care delivery system achievedover the last decade. Existing primary care capac-ity must be preserved or replaced.

Plans or hospital restructurings/closures mustensure that existing primary care capacity is pro-tected and expanded into shortage areas. In additionto the physician capacity analyzed in this report,hospital restructurings/closures also would likelydecrease the capacity provided by other primary careproviders. Although shortages still exist in parts othe City, great strides have been made over the last

decade in expanding New York Citys primary careinrastructure, especially by the Health and Hospi-tals Corporation. Policymakers must ensure that anyeciency gained by downsizing hospitals does notexacerbate disparities in another part o the system.Tey also must ensure that primary care resourcesare redistributed in a manner that will meet patientsneeds and produce system-wide savings over time.Specically, decisions must address:


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Where patients will be redirected oroutpatient services;

Whether area hospitals can accommodate the in-

creased emergency room utilization and displacedAmbulatory Care Sensitive (ACS) hospitalizationsexpected to result rom any reduction o primarycare capacity caused by hospital closure; and

Deliberate strategies and unding to create addi-tional needed primary care capacity.

Recommendation 3: Resource availability anddistribution decisions must be analyzed and ad-dressed at the community level.

Because large area analyses mask underlying varia-tions, it is essential that any decisions about restruc-turing the health care system be based on communi-ty-level data. For example, using zip code data revealscommunity-level dierences that borough level datamasks. (See Appendix A.) Such decisions must bebased not only on a circumscribed geography butalso on socioeconomic considerations, includingspecic cultural/language requirements. Tis type oanalysis typically reveals the need or community-based health care delivery.

Recommendation 4: While this report limitsdiscussion to primary care physician capacity,New York State urgently needs a comprehensiveprimary care strategy.

Te ocus o public policy and health nancing todate has been on the hospitals. Ample research showsthat a strong primary care system is necessary to

reduce health system costs and improve health out-comes over the mid- and long-term. Tereore, the

State needs to undertake a deliberate primary careinitiative that includes:

Reorming New York States reimbursement

system that currently underpays or primary careand imposes disincentives or building the eec-tive primary care system needed to avoid unneces-sary hospitalization and eectively link patients tohospital care when needed.

Addressing the shortage o primary care physiciansand other providers available to low-income NewYorkers.

Reconguring the existing primary care system

into the model o a health care home, with anemphasis on prevention, health promotion, andearly detection and treatment. Tis includes ensur-ing that every New Yorker has a personal primarycare provider as well as continuity and care man-agement. It means that providers need to be sup-ported in adopting and using health inormationtechnology and implementing proven best practicesin access, prevention, and care management.

Te State should dedicate a portion o the majorpublic resources now becoming available to restruc-ture the health system. o support such an initia-tive, these resources include $1 billion rom theHealthcare Eciency and Aordability Law or NewYorkers (HEAL-NY), the much-anticipated $1.5billion in Federal-State Health Reorm Partnership(F-SHRP), and monies available as the resulto or-prot conversions o not-or-protinsurance companies.

1United Hospital Fund, Health Insurance Coverage in New York, 2002-2003, October, 2005.

2According to the New York State Department of Health, there were 3.15 million Medicaid-enrolled New York City residents in 2005, of which 1.9 million reside in shortage areas described

in the body of this report. Medicaid-enrolled residents are used in this report as a proxy for all low-income residents. We recognize that this is an undercount of the number of low-income New

Yorkers since it excludes those who are uninsured or underinsured. The United Hospital Fund estimated 1.7 million uninsured New York City residents under age 65 in 2002-2003.

3Center For Health Wordforce Studies, SUNY Albany, NYS Physician Re-Registration Survey 2004-2006.

4Health Resources and Services Administration (HRSA) Health Professional Shortage Area benchmarks. As dened by HRSAs Bureau of Primary Health Care and used nationwide in

designating Health Professional Shortage Areas, an area is deemed Over-utilizedherein identied as Stressedif it has a rate of 2,000 to 2,999 Medicaid-enrolled residents per primary care

physician full-time equivalent (FTE) or deemed Underservedherein identied as Serious Shortageif it has a rate of 3,000+ Medicaid-enrolled residents per primary care physician FTE.


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practitioners) and physician residents, who workprimarily in hospital settings are essential contribu-tors to primary care capacity or low-income NewYorkers. Tese providers were not included in thisreport because data are not readily available at thezip code and payor levels. Further analysis needs tobe done to provide a more robust depiction o avail-able capacity and existing shortages.

Additionally, this report does not address a numbero other access issues. Physician supply is only one omany contributing actors when considering accessto health care. Health insurance coverage, languageand cultural access, quality o care, and institu-tional and operational eectiveness also are criticalto ensuring access to health care. Tus, increasing

physician capacity alone will not eliminate all accessto care issues. For example, many uninsured NewYorkers are likely to still experience barriers to access-ing care and disparities compared to insuredNew Yorkers.

Specically, our analysis revealed six major ndings:

1. More than hal o New York City communi-ties have a signifcant shortage o primarycare physicians serving low-income NewYorkers.2 Although 39% o New York Citysresidents are enrolled in Medicaid, they haveaccess to just 25% o the primary care physi-cians based in the City.

We identied and mapped Stressed and Seri-ous Shortage areas applying the Health Resourcesand Services Administrations (HRSA) populationto physician ratio benchmarks4 to the Medicaid-en-rolled population to ascertain the adequacy o pri-mary care physician availability or low-income NewYorkers. Te ratios represent Medicaid enrollees perprimary care physician ull-time equivalent (FE)serving Medicaid patients.

Serious Shortage = 3,000 residents to 1 FEprimary care physician or over

Stressed = 2,000 - 2,999 residents to 1 FEprimary care physician

Tis shortage in New York City is evidenced by theollowing: (See able 1.)

Residents o 64 zip codes5 have an average o4,682 Medicaid enrollees per 1 FE primarycare physician.

Residents o 36 zip codes have an average o2,422 Medicaid enrollees per 1 FE primarycare physician.

Although 39% o New York Citys residents areenrolled in Medicaid they have access to just25% o the primary care physicians based in theCity. (See able 1.)

Findings


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Map 1: Nearly 60% o the Citys zip codes have an inadequate supply o primary care physicians or low-income New Yorkers.

Tis map identies neighborhoods where the primary care physician supply available to low-income NewYorkers is either Stressed or experiencing a Serious Shortage. It shows that 100 zip codes have too ew

physicians available to low-income residents. Note that the methodology assumed that residents receive care inthe zip code in which they live.6

6The analysis and maps in the body of this report are based on the assumption that patients receive care in the zip code in which they live. Recognizing that residents may actually seek care

outside of their neighborhoods, we undertook a separate analysis, described in Appendix B, that applied a travel-adjustment method to illustrate the potential effect travel may have on physi-

cian supply. It is difcult to predict actual travel behaviorespecially given a number of factors, including cultural, socioeconomic, and other needs and/or barriersor to determine the best

method for modeling the impact of that behavior on assessments of physician availability. Consequently, true primary care physician availability likely falls between the non-travel adjusted and

travel-adjusted analyses. It is important to note that, even with an adjustment for potential travel, the physician capacity available to low-income residents of much of Brooklyn, Queens, and

Staten Island (38% of the Citys zip codes) remains inadequate.


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In total, over 1.9 million Medicaid enrollees cur-rently live in areas with an inadequate primary carephysician supply available to Medicaid Enrollees.Tese areas include but are not limited to:

Kingsbridge/Riverdale, Bronx Northeast, Bronx Bedord Stuyvesant, Brooklyn Canarsie/Flatlands, Brooklyn East New York, Brooklyn Flatbush, Brooklyn Greenpoint, Brooklyn Williamsburg/Bushwick, Brooklyn Bayside/Little Neck, Queens Jamaica, Queens Southeast Queens

Port Richmond, Staten Island Stapleton, Staten Island Willowbrook, Staten Island

2. Unnecessary emergency room use andavoidable hospitalizations are particularlyhigh in low-income communities.

wo out o every ve emergency room visitsover 1million visits citywideare or conditions that canor should have been prevented or treated in primarycare settings. (See able 2.)

Inadequate primary care is evidenced by Ambula-tory Care Sensitive (ACS) admission ratesthat is,admissions or conditions that could have been pre-vented or treated on an ambulatory care basis. Teserates are indicators o shortcomings in the primary

care system.

ACS rates exceed the citywide average (17 dischargesper 1,000 population) in more than one-third o theCitys zip codes. (See Maps 2 and 3.)

Te rates are lower or children (age 0-17 years)

(Map 2) than or adults (age 18-64 years). (SeeMap 3.) Lower rates or children likely refect ex-panded insurance coverage, notably through ChildHealth Plus, which enhances patients access to

primary care.

As shown on Appendix D, the ACS rates are high-est in the Citys designated Health ProessionalShortage Areas,7 notably:

South Bronx Northern Manhattan Central and Northeast Brooklyn Northern Staten Island Long Island City, Queens Jamaica, Queens

7 Health Professional Shortage Area means any of the following which the Secretary of the US Department of Health and Human Services determines has a shortage of healthprofessionals: (1) An urban or rural area (which need not conform to the geographic boundaries of a political subdivision and which is a rational area for the delivery of health services); (2) a

population group; or (3) a public or nonprot private medical facility.


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Map 2: Children in 62 (35%) o New York City Zip Codes Experience High Rates o Avoidable Hospital-izations

Tis map identies the areas in New York City with high rates o avoidable hospitalizations among 0-17 yearolds. Tis is strong evidence o the impact o inadequate physician capacity. (See Appendix C or hospital key.)

Not all hospitals that serve residents o shortage areas are noted on this map. Hospitals are identied only ithey are physically located in a shortage area zip code.


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Map 3: Adults in 74 (42%) o New York City Zip Codes Experience High Rates o Avoidable Hospitaliza-tions

Tis map identies the areas in New York City with high rates o avoidable hospitalizations among 18-64 yearolds. Tis is strong evidence o the impact o inadequate physician capacity. (See Appendix C or hospital key.)

Not all hospitals that serve residents o shortage areas are noted on this map. Hospitals are identied only ithey are physically located in a shortage area zip code.


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3. Tirty-two percent o the Citys primarycare physicians available to low-incomeresidents528 o 1,665 FEsare based

in hospitals, making access to care or low-income New Yorkers highly vulnerable tohospital closures.3

Low-income New Yorkers are twice as reliant asNew Yorkers as a whole on hospitals as their sourceor primary care. In contrast, 16% o the Citysoverall primary care physician supply ishospital-based.

Ninety-ve percent o the Citys zip codes would bedesignated as Serious Shortage or as Stressed,absent the hospital-based primary care physiciansupply or Medicaid Enrollees. (See Map 4.)

4. Hospital restructuring/closure will increasethe stress on an already strained primarycare system.

As stated, New York City already has a shortage oprimary care physicians serving low-income resi-

dents. Tose New Yorkers also are heavily reliant onhospitals as their source or primary care. Tus clos-ing outpatient departments and emergency roomswithout providing alternative care sources wouldsimply increase the current shortage o primary carecapacity in New York City and leave low-incomeresidents without the care they need.

As an example o the potential impact o hospitalclosures on primary care capacity, we consideredthe closure o a hospital the size o Jacobi Medi-cal Center (Jacobi). An estimated 46% (42,550) oJacobis 92,500 emergency room visits in 2004 were

non-emergent and primary care treatable. Accommo-dating this need would require a 15,000 square ootambulatory care center staed by at least 10 ull-time

primary care physicians. Without assertive measuresto develop this alternative, primary care capacityshortages would merely increase.

5. New York Citys ambulatory care system issignifcantly underdeveloped compared toits inpatient system.

New York Citys health care system is overly relianton inpatient, hospital-based care and under-invested

in outpatient care.8

New York City has 33% more inpatient beds andinpatient days (3.7 beds and 1,013 inpatient daysper 1,000 population) than the United States as awhole (2.8 beds and 683 inpatient days per 1,000population).

Meanwhile, New York City provides 38% eweroutpatient visits (1,391 per 1,000 population)than the United States as a whole (1,932 per 1,000

population).

6. Ample research shows that, while preserv-ing and enhancing primary care capacityrequires up-ront investment, it produceshealth system savings and improved healthoutcomes over the mid-and long-term.

Although not a specic nding o this study, researchshows that eective primary care results in overallcost savings. (Data is most readily available or Feder-ally-Qualied Health Centers [FQHCs] since theyare unded through a ederal program. Tey provide

8Presentation by New York City Department of Health and Mental Hygiene Commissioner Tom Frieden.


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one example o the cost-saving potential o goodprimary care.)

In New York State, Medicaid patients treated byFQHCs cost taxpayers 22% less in outpatientspending and 41% less in inpatient spending thanMedicaid patients treated in other settings.9

A ve-state study showed that Medicaid patientstreated in community-based primary care centerswere signicantly less likely to use emergencyrooms or to be hospitalized or ACS conditions.10

According to one study, chronically ill patientswho were regular health center users save NewYork State taxpayers in inpatient costs, specically,diabetics treated in health centers save 62% in in-patient costs and asthmatics save 44% in inpatientcosts.11 We would expect that similar primary caremodels could achieve similar results.

Medicare costs are inversely related to the supply oprimary care physicians: the greater the supply oprimary care, the lower the Medicare

spending rate.12

9Duggar, B.C., Keel, K., Balicki, B., and Simpson, E., Health Services Utilization and Costs to Medicaid of AFDC Recipients in New York Served and Not Served by Community Health Centers,

Center for Health Policy Studies, 1994.

10Falik, M. et al. Ambulatory Care Sensitive Hospitalizations and Emergency Room Visits: Experiences of Medicaid patients Using Federally Qualied Health Centers, 2001, Medical Care

39(6):551-56.

11Duggar, B.C., Keel, K., Balicki, B., and Simpson, E., Health Services Utilization and Costs to Medicaid of AFDC Recipients in New York Served and Not Served by Community Health Centers,

Center for Health Policy Studies, 1994.

12Sara Rosenbaum, JD; Peter Shin, PhD; Ramona Perez; and Trevine Whittington. Laying the Foundation: Health System Reform in New York State and the Primary Care Imperative,

February 2006.


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Based on the ndings in this analysis, we recommend

the ollowing:

Recommendation 1: New York State policymakersmust address current underlying shortages in theavailability o primary care resources.

Although 39% o New York Citys residents areenrolled in Medicaid, they have access to just 25% othe primary care physicians based in the City. NewYork City needs to eliminate primary care short-ages or Medicaid-enrolled residents to meet Federalcapacity benchmarks.

Recommendation 2: At minimum, hospital re-structurings/closures should not undo the expan-sion o the primary care delivery system achievedover the last decade. Existing primary care capac-ity must be preserved or replaced.

Plans or hospital restructurings/closures must ensurethat existing primary care capacity is protected and

expanded into shortage areas. In addition to thephysician capacity analyzed in this report, hospitalrestructurings/closures also would likely decrease thecapacity provided by other primary care providers.Although shortages still exist in parts o the City,great strides have been made over the last decade inexpanding New York Citys primary care inrastruc-ture, especially by the Health and Hospitals Corpora-tion. Policymakers must ensure that any eciencygained by downsizing hospitals does not exacerbatedisparities in another part o the system. Tey also

must ensure that primary care resources are redistrib-uted in a manner that will meet patients needs andproduce system-wide savings over time. Specically,decisions must address:

Where patients will be redirected or

outpatient services;

Whether area hospitals can accommodate the in-creased emergency room utilization and displacedAmbulatory Care Sensitive (ACS) hospitalizationsexpected to result rom any reduction o primarycare capacity caused by hospital closure; and

Deliberate strategies and unding to create addi-tional needed primary care capacity.

Recommendation 3: Resource availability anddistribution decisions must be analyzed and ad-dressed at the community level.

Because large area analyses mask underlying varia-tions, it is essential that any decisions about restruc-turing the health care system be based on communi-ty-level data. For example, using zip code data revealscommunity-level dierences that borough level datamasks. (See Appendix A.) Such decisions must be

based not only on a circumscribed geography butalso on socioeconomic considerations, includingspecic cultural/language requirements. Tis type oanalysis typically reveals the need or community-based health care delivery.

Recommendation 4: While this report limitsdiscussion to primary care physician capacity,New York State urgently needs a comprehensiveprimary care strategy.

Te ocus o public policy and health nancing todate has been on the hospitals. Ample research showsthat a strong primary care system is necessary toreduce health system costs and improve health out-comes over the mid- and long-term. Tereore, the

Recomendations


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State needs to undertake a deliberate primary careinitiative that includes:

Reorming New York States reimbursement systemthat currently underpays or primary care andimposes disincentives or building the eectiveprimary care system needed to avoid unnecessaryhospitalization and eectively link patients to hos-pital care when needed.

Addressing the shortage o primary care physicians

and other providers available to low-incomeNew Yorkers.

Reconguring the existing primary care systeminto the model o a health care home, with anemphasis on prevention, health promotion, andearly detection and treatment. Tis includes ensur-ing that every New Yorker has a personal primarycare provider as well as continuity and care man-agement. It means that providers need to be sup-ported in adopting and using health inormation

technology and implementing proven best practicesin access, prevention, and care management.

Te State should dedicate a portion o the majorpublic resources now becoming available to restruc-ture the health system. o support such an initia-tive, these resources include $1 billion rom theHealthcare Eciency and Aordability Law or NewYorkers (HEAL-NY), the much-anticipated $1.5billion in Federal-State Health Reorm Partnership

(F-SHRP), and monies available as the resulto or-prot conversions o not-or-protinsurance companies.


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Methodology & Data Sources

Te Primary Care Development Corporation(PCDC) and the New York City Health and Hospi-tals Corporation (HHC) used the ollowing method-ology to analyze primary care physician capacity andpopulation vulnerability at zip code and neighbor-hood levels in New York City. While a more detailedpopulation-specic assessment is needed to makeplanning decisions or any particular community,this report is an important starting point in assessingthe level o basic capacity that could disappear as aresult o hospital closures. It also highlights the needto develop alternative primary care capacitywith orwithout hospital closures

Methodology

We identied the current primary care capacity mea-sured by primary care physician ull-time equivalentsat the zip code, neighborhood, and borough level.

We categorized these physicians as community-based or hospital-based and quantied theiravailability to Medicaid Enrollees as described in thesections titled Primary Care Physicians and Primary

Care Physicians Serving Medicaid-Enrolled Residentsunder Data Sources below.

We then calculated Population-to-Physician ratios atthe zip code, neighborhood, and borough levels orthe population as a whole and or Medicaid enrolleesas a specic subset o the total population.

We identied and mapped stressed/shortage areas orboth the overall population and Medicaidenrollees at the zip code, neighborhood, and boroughlevels by applying the Population-to-Physician Ratiobenchmarks13 below to illustrate the adequacy o theexisting primary care capacity:

Serious Shortage = 3,000:1 or overStressed = 2,000:1 to 2,999:1

Not all eligible shortage areas have gone through theormal designation process. Te areas categorized asshortage areas in this report may not coincide withareas designated by HRSA as Health ProessionalShortage Areas.

We supplemented the physician gap analysis withdata on emergency room use and hospitalizations orACS conditions, which suggest inadequacies in theexisting primary care system and point to potentialcost savings attendant to substituting primary careor higher cost service delivery methods/settings.

Data Sources

Primary Care Physicians Te number o ull-timeequivalent (FE) primary care physicians was cal-culated by the SUNY Center or Health WorkorceStudies using results rom a survey the Center con-ducted or the New York State Department o Edu-cations Division o Proessional Licensing Services,or physicians applying or re-licensing between 2004and 2006. Physicians were classied as primary care

physicians based on their sel-reporting o their mainspecialty as: amily practice, internal medicine, gen-eral practice, pediatrics, or obstetrics/gynecology. Tephysician supply was designated hospital-based orcommunity-based based on practice hours reportedat each site. FEs were calculated based on 36 hoursper 1 FE. Tis survey is believed to be one o themost complete tallies o physician capacity availableor New York City.

Primary Care Physicians Serving Medicaid-En-rolled Residents Te physician supply servingMedicaid-enrolled residents was based on the report-ed payer mix rom the physician survey.

Zip Codes A total o 173 residential zip codes wereused in this analysis. Te 21 point zip codes, used

13Health Resources and Services Administration (HRSA) Health Professional Shortage Area benchmarks. As dened by HRSAs Bureau of Primary Health Care and used nationwide in

designating Health Professional Shortage Areas, an area is deemed Over-utilizedherein identied as Stressedif it has a rate of 2,000 to 2,999 Medicaid-enrolled residents per primary care

physician full-time equivalent (FTE) or deemed Underservedherein identied as Serious Shortageif it has a rate of 3,000+ Medicaid-enrolled residents per primary care physician FTE.


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or post oce boxes and specic buildings or institu-tions, have been incorporated into their encompass-

ing residential zip codes. Excluded, since they houseneither residents nor primary care physicians, arethe two airport zip codes (11371 or LaGuardia and11430 or JFK) and the Brooklyn NavyYard (11251.)

Population Data on population were based onClaritas/NPDC estimates or 2005.

Medicaid Enrollees Medicaid Enrollees are de-rived rom the New York State Department o

Healths Medicaid enrollment gures, by zip code,or ederal Fiscal Year 2005.

Outpatient Visits or able 3 Billable visits re-ported in the United Hospital Funds Health CareAnnual Updates or 2001 and 2005.

Emergency Room Visits o identiy non-emer-gent and primary care treatable visits, an algorithmdeveloped by NYUs Center or Health and PublicService Research was applied to SPARCS data pro-vided by the New York State Department o Healthor patients treated in emergency rooms in New YorkCity during 2004.

Hospitalization Rates or Ambulatory Care Sen-sitive Conditions Ambulatory care sensitivehospitalization rates can be used to understand andevaluate the perormance o the ambulatory healthcare system at the local level. Selected by an advisorypanel o physician experts, ambulatory care sensi-

tive (ACS) conditions are those or which timely,eective outpatient care can prevent hospitalizationby preventing the onset o the illness o condition,controlling an acute episode o illness, or managinga chronic disease or condition.14 NYUs Center orHealth and Public Service Research applied its ACS

categorization model to age-adjusted SPARCS dataor New York City residents hospitalized anywhere in

New York State during 2004. ACS rates are expressedas admissions per 1,000 population.

14United Hospital Fund, New York City Community Health Atlas, 2002


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Appendices

Appendix A

It is vital that need and capacity be assessed at the local level. For example, as the two maps below illustrate,primary care physician capacity viewed at the borough level, as shown in Map A-1, masks the underlyingshortages that exist at the zip code level shown in Map A-2.

Map A-


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Map A-2


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Appendix B

Te analysis and maps in the body o this report assume that patients receive care in the zip code in which theylive. Recognizing that residents may actually seek care outside o their neighborhoods, we undertook a sepa-rate analysis, using a travel-time adjustment developed by New York Universitys Center or Health and Public

Service Research, to illustrate the potential eect travel may have on physician supply. Having applied thetravel-time adjustment, we identied, in Map B-1, the neighborhoods where the primary care physician supplyavailable to Medicaid Enrollees, as a proxy or all low-income New Yorkers, is either Stressed or experiencinga Serious Shortage.

Map B-

We chose to present this analysis as an appendix for a number of reasons:

1. It is difcult to predict actual travel behaviorespecially given a number of factors, including cultural, socioeconomic, and other needs and/or barriers; and

2. It is difcult to reliably model that behavior.

We believe that true capacity likely falls between the non-travel adjusted and travel-adjusted analyses. It is important to note that, even with an adjustment for potential travel, the physician

capacity available to low-income residents of much of Brooklyn, Queens, and Staten Island (38% of the Citys zip codes) remains inadequate.


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Appendix C

Tis list identies all hospitals in New York City.

1 CABRINI MEDICAL CENER2 HOSPIAL FOR JOIN DISEASES3 NY EYE AND EAR INFIRMARY4 BEH ISRAEL MEDICAL CENER5 SVCMC/S VINCENS HOSPIAL

MANHAAN6 NYU MEDICAL CENER7 BELLEVUE HOSPIAL CENER8 SVCMC/S VINCENS MIDOWN HOSPIAL9 S LUKES ROOSEVEL HOSPIAL/

ROOSEVEL10 LENOX HILL HOSPIAL11 MANHAAN EYE, EAR, & HROA

HOSPIAL12 MEMORIAL HOSPIAL FOR CANCER/

SLOAN KEERING13 NEW YORK PRESBYERIAN HOSPIAL/

WEILL CORNELL14 ROCKEFELLER UNIVERSIY HOSPIAL15 HOSPIAL FOR SPECIAL SURGERY16 S LUKES ROOSEVEL HOSPIAL/S LUKES17 MOUN SINAI HOSPIAL18 MEROPOLIAN HOSPIAL CENER19 NEW YORK PRESBYERIAN

HOSPIAL/COLUMBIA

20 NEW YORK PRESBYERIAN HOSPIAL//ALLEN PAVILLION21 NORH GENERAL HOSPIAL22 HARLEM HOSPIAL CENER23 NYU DOWNOWN HOSPIAL24 COLER MEMORIAL HOSPIAL25 GOLDWAER MEMORIAL HOSPIAL29 SAEN ISLAND UNIVERSIY HOSP/NORH30 SAEN ISLAND UNIVERSIY HOSP/SOUH31 SVCMC/S VINCENS HOSPIAL

SAEN ISLAND32 LINCOLN MEDICAL CENER33 BRONX-LEBANON HOSPIAL

CENER/FULON34 BRONX-LEBANON HOSPIAL

CENER/CONCOURSE35 S BARNABAS HOSPIAL37 CALVARY HOSPIAL39 WESCHESER SQUARE MEDICAL CENER

40 MONEFIORE MED CR/ WEILER41 JACOBI MEDICAL CENER42 OUR LADY OF MERCY MED CR43 NORH CENRAL BRONX HOSPIAL44 MONEFIORE MED CR/MOSES45 LONG ISLAND JEWISH MEDICAL CENER46 WESERN QUEENS COMMUNIY HOSPIAL47 LONG ISLAND COLLEGE HOSPIAL48 BROOKLYN HOSPIAL CENER49 KINGSBROOK JEWISH MEDICAL CENER50 UNIVERSIY HOSPIAL OF BROOKLYN51 KINGS COUNY HOSPIAL CENER52 WOODHULL MEDICAL CENER53 BROOKDALE HOSPIAL MEDICAL CENER55 INERFAIH MEDICAL CENER/

S JOHNS EPISCOPAL56 NEW YORK MEHODIS HOSPIAL57 MAIMONIDES MEDICAL CENER58 LUHERAN MEDICAL CENER60 VICORY MEMORIAL HOSPIAL61 NEW YORK COMMUNIY HOSPIAL62 BEH ISRAEL MEDICAL CENER/

KINGS HIGHWAY HOSPIAL63 CONEY ISLAND HOSPIAL64 WYCKOFF HEIGHS MEDICAL CENER

66 NEW YORK HOSPIAL QUEENS68 FLUSHING HOSPIAL MEDICAL CENER70 SVCMC/S JOHNS QUEENS HOSPIAL71 ELMHURS HOSPIAL CENER72 PARKWAY HOSPIAL73 NORH SHORE UNIVERSIY HOSPIAL-

FORES HILLS74 JAMAICA HOSPIAL MEDICAL CENER75 SVCMC/MARY IMMACULAE HOSPIAL76 QUEENS HOSPIAL CENER77 S JOHNS EPISCOPAL HOSPIAL-SO SHORE78 PENINSULA HOSPIAL CENER

Te hospitals that had been listed as 26, 27, 28, 36, 38, 54, 59,65, 67, & 69 have been closed and so have been excluded romthe map and the legend.


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Appendix D

Tis map identies the areas in the City with high admission rates or ACS conditions or 18 - 64 year oldsas well as the areas that are ormally designated as Health Proessional Shortage Areas (HPSA). Note that notall areas that may be eligible or HPSA designation have gone through the ormal Federal designation process.

Consequently not all shortage areas are HPSA designated.

Map D

primary care capacity shortage & the potential impact of hospital closures

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