Reports > The Health Care Workforce in Eight States: Education, Practice & Policy > New York

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On this page: Project Description | Study Methodology | State Summary | Workforce Supply and Demand | Health Professions Education | Physician Practice Location | Licensure and Regulation of Practice | Improving the Practice Environment | Exemplary Workforce Legislation, Programs and Studies | Policy Analysis | Data Sources

PROJECT DESCRIPTION

Historically, both federal and state governments have had a role in developing policy to shape the health care workforce.  The need for government involvement in this area persists as the private market typically fails to distribute the health workforce to medically underserved and uninsured areas, provide adequate information and analysis on the nature of the workforce, improve the racial and ethnic cultural diversity and cultural competence of the workforce, promote adequate dental health of children, and assess the quality of education and practice. 

It is widely agreed that the greatest opportunities for influencing the various environments affecting the health workforce lie within state governments. States are the key actors in shaping these environments, as they are responsible for:

• financing and governing health professions education;
• licensing and regulating health professions practice and private health insurance;
• purchasing services and paying providers under the Medicaid program; and
• designing a variety of subsidy and regulatory programs providing incentives for health professionals to choose certain specialties and practice locations.

Key decision-makers in workforce policy within states and the federal government are eager to learn from each other.  This initiative to compile in-depth assessments of the health workforce in 8 states is an important means of insuring that states and the federal government are able to effectively share information on various state workforce data, issues, influences and policies. 

Products of this study include individual health workforce assessments for each of the eight states and a single assessment that compares various data and influences across the eight states.  In general, each state assessment provides the following:

1) A summary of health workforce data, available resources and a description of the extent the state invests in collecting workforce data.  [Part of this information has been provided by the Bureau of Health Professions];

2) A description of various issues and influences affecting the health workforce, including the state’s legislative and regulatory history and its current programs, financing and policies affecting health professions education, service placement and reimbursement, planning and monitoring, and licensure/regulation;

3) An assessment of the state’s internal capacity and existing strategies for addressing the above workforce issues and influences; and

4) An analysis of the policy implications of the state’s current workforce data, issues, capacity and strategies.

The development of the project’s data assimilation strategy, content and structure was guided by an expert advisory panel.  Members of the advisory panel included both experts in state workforce policy (i.e., workforce planners, researchers and educators) and, more broadly, influential state health policymakers (i.e., state legislative staff, health department officials).  The advisory panel has helped to ensure the workforce assessments have an appropriate content and effective format for dissemination and use by both state policymakers and workforce experts/officials.

STUDY METHODOLOGY

Study Purpose and Audience

Key decision-makers in workforce policy within states and the federal government are eager to learn from each other.  Because states increasingly are being looked to by the federal government and others as proving grounds for successful health care reform initiatives, new and dynamic mechanisms for sharing innovative and effective state workforce strategies between states and with the federal government must be implemented in a more frequent and far reaching manner.  This initiative to compile comprehensive capacity assessments of the health workforce in 8 states is an important means of insuring that states and the federal government are able to effectively share information on various state workforce data, issues and influences.

Each state workforce assessment report is not intended to be voluminous; rather, information is presented in a concise, easy-to-read format that is clearly applicable and easily digestible by busy state policymakers as well as by workforce planners, researchers, educators and regulators.

Selection of States

NCSL, with input from HRSA staff, developed a methodology for identifying and selecting 8 states to assess their health workforce capacity.  The methodology included, but was not limited to, using the following criteria:

a.   States with limited as well as substantial involvement in one or more of the following areas: statewide health workforce planning, monitoring, policymaking and research;

b.   States with presence of unique or especially challenging health workforce concerns or issues requiring policy attention;

c.   States with little involvement in assessing health workforce capacity despite the presence of unique or especially challenging health workforce concerns or issues requiring policy attention;

d.   Distribution of states across Department of Health and Human Services regions;

e.   States with Bureau of Health Professions (BHPr) - supported centers for health workforce research and distribution studies;

f. States with primarily urban and primarily rural health workforce requirements; and

g. States in attendance at BHPr workforce planning workshops or states that generally have interest in workforce modeling.

Collection of Data

NCSL used various means of collecting information for this study.  Methods exercised included:

a. Phone and mail interviews with state higher education, professions regulation, and recruitment/retention program officials;

b. Custom data tabulations by national professional trade associations and others (i.e., Quality Resource Systems, Inc.; Johns Hopkins University School of Public Health) with access to national data bases;

c. Tabulations of data from the most recent edition of federal and state government databases (e.g., National Health Service Corps field strength);

d. Site visit interviews with various officials in the ten  profile states;

e. Personal phone conversations with other various state and federal government officials;

f. Most recently available secondary data sources from printed and online reports, journal articles, etc.; and

g. Comments and guidance from members of the study’s expert advisory panel.

STATE SUMMARY

Although New York is largely metropolitan, the upper portion of the state has a significant rural population.  The state’s minority and ethnic population accounts for over a third of New York’s total population.  By various indicators, New York residents enjoy higher access to health care services than most states.

New York state government has a long history of addressing state health workforce issues in the context of larger health system changes and reforms.  Until recently, most public third party payment rates to the state’s hospital and health care system historically have been centrally regulated by the state. The state has numerous grant and loan programs intended to improve the supply of health professionals in primary care and long-term care disciplines and in rural and indigent underserved communities.  State officials rank their initiatives to recruit medical students from rural or underserved areas and state support for health professions education in underserved communities as having a major impact on recruiting and retaining health professionals to needy areas of the state. In addition, New York devotes significant attention to better understanding its health workforce needs through collection and analysis of data on the state’s health professions in training and practice.  The Center for Health Workforce Studies at the State University of New York in Albany routinely provides state officials and others respected reports and analyses of physician and nurse supply in the state.  The state hospital and nursing associations, as well as the state’s major health professional licensing boards, also regularly collect workforce data on members or licensees that is made available to state policymakers.

A recent economic recession and growing shortages of nurses and other health professionals in the state have focused attention on the need to establish a major new state-funded health workforce retraining initiative. The latest initiative is supported by a coalition of hospitals, nursing homes, nurse executives, home care agencies and adult care facilities.  Health care workers in these settings are heavily unionized in New York, and such unions have significant influence on state policymakers. In early 2002, a $3 billion health care plan proposed as part the new fiscal year budget by New York’s governor (who is seeking re-election in 2002)—approved by the Legislature and endorsed by the state’s powerful hospital union—increases salaries for health care employees and restores some reductions in Medicaid services that were previously proposed. The plan also provides $80 million in grants to hospitals, nursing homes and other qualified agencies for recruitment, retention and training of health care workers, and awards $28 million for various primary care initiatives and projects. 

New York has the second highest proportion of practicing physicians per 100,000 population of any state in the country.  However, despite such overall abundance of physicians statewide, there are many areas of the state—particularly rural in nature—where supply of specialty and primary care physicians is low and access to care is limited.  New York is a major producer of physicians and fares well at retaining them. 

With over 300,000 licensed nurses, New York has the second largest population of nurses in the nation.  Despite this abundance of nurses, there are indications in New York of a growing nursing shortage.  Recent surveys find that three-quarters of the state’s hospitals report nursing shortages, particularly outside of New York City.  The state has been slow to provide support to address the shortage problem.  Legislation in 2001 calling for a limitation on mandatory overtime for nurses, creation of a minimum nurse staffing formula, whistleblower protection, creation of a statewide nurse staffing center, and establishment of a state nursing scholarship program await lawmaker action in 2002.

New York has focused much less attention on the dental and pharmacy workforce.  As elsewhere, the shortage of dentists who serve Medicaid recipients is a problem in New York.  Concerns by dentists over low Medicaid payment rates resulted in a 2000 suit of the state by the state dental association.  As a result of the suit, dentists won the right to receive incremental Medicaid rate increases.

I.  WORKFORCE SUPPLY AND DEMAND

Arguably, it is most important initially to understand the marketplace for a state’s health care workforce.  How many health professionals are in practice statewide and in medically underserved communities?  What are the demographics of the population served?  How is health care organized and paid for in the state?  This section attempts to answer some of these questions by presenting state-level data collected from various sources.

* As defined by the U.S. Office of Management and Budget

Sources:  U.S. Census Bureau, AARP.

Over 90% of New York residents live in metropolitan areas.

Sources: CDC, AARP, GAO.

Eight-seven percent of New York adults report having a routine physical exam within the past two years.

HPSA = Health Professional Shortage Area

* It is commonly believed that there are additional areas in the state that may be eligible to receive HPSA designation.

Sources: KFF, AARP, BPHC-DSD.

Less than 9% of New York residents report not obtaining health care due to cost.

RN= Registered Nurse, LPN= Licensed Practical Nurse, CNM= Certified Nurse Midwife, NP= Nurse Practitioner

CRNA= Certified Registered Nurse Anesthetist

Source: HRSA-BHPr.

New York has more physicians, physician assistants, nurses, pharmacists, dentists and dental hygienists per 100,000 population than the U.S. as a whole.

HPSA= Health Professional Shortage Area

Source: BHPr-NHSC.

New York’s National Health Service Corps field strength per 10,000 HPSA population is lower than the national average.

MCOs = Managed Care Organizations    HMOs = Health Maintenance Organizations    OB/GYN = Obstetrician/Gynecologist

* This requirement does not preclude MCOs from including additional professions on their provider panels.

Sources: HPTS, AARP.

Thirty-four percent of New York residents receive health care from an HMO.

¹ Generally seen as an indicator of significant participation in the Medicaid program.

² Denominator number from HRSA State Health Workforce Profile, December 2000.

*  Numerator data for physicians and nurse practitioners from state Medicaid agencies were unusable: many professionals were apparently double-counted, perhaps due to varying participation in different health plans.

Sources: State Medicaid programs, Norton and Zuckerman “Trends”, HPTS, AARP.

Medicaid physician fees actually decreased between 1993 and 1998.

II.  HEALTH PROFESSIONS EDUCATION

State efforts to help ensure an adequate supply of health professionals can be understood in part by examining data on the state’s health professions education programs–counts of recent students and graduates, amounts of state resources invested in education, and other factors.  State officials can gauge how well these providers reflect the state’s population by also examining how many students and graduates are state residents or minorities.  Knowing to what extent states are also investing in primary care education and how many medical school graduates remain in-state to complete residencies in family medicine is also important.

¹ Denominator number is state population from 2000 U.S. Census.

Sources: AAMC, AAMC Institutional Goals Ranking Report, AACOM, Barzansky et al. “Educational Programs”, State higher education coordinating boards.

Just 60% of newly entering medical students in New York are state residents.

¹ Includes estimated number of osteopathic residencies/residents not accredited by the Accreditation Council for Graduate Medical Education.

² Does not include residents from Canada.

³ Explicit payments for both direct and indirect GME cost.

⁴ Funds largely are for graduate education.

⁵Dollar amounts refer largely to funding for family medicine training programs. However, these funds that flow directly to teaching hospitals are not necessarily earmarked by the state for graduate medical education.

Sources: AMA, AMA State-level Data, AACOM, State higher education coordinating boards, Henderson “Funding”, Oliver et al. “State Variations.”

Almost half of New York physician residents are international medical graduates—a proportion that is double the national average.

¹ Denominator  number is state population from 2000 U.S. Census.

2 Dollar amounts refer largely to funding family medicine training programs. However, these funds that flow directly to teaching hospitals are not necessarily earmarked by the state for graduate medical education.

Sources: AAFP, AAFP State Legislation, Kahn et al., Pugno et al. and Schmittling et al. “Entry of U.S. Medical School Graduates”.

New York has only half as many graduates who were first year residents in family medicine as the U.S. as a whole.

¹ Annual figure for Associate, Baccalaureate, Masters and Doctoral students/graduates for most recent years available.

² Denominator number is the state population from the 2000 U.S. Census.

Sources: NLN, AACN, State higher education coordinating boards.

New York nursing school enrollments and graduations declined between 1999 and 2000.

* Denominator number is state population from 2000 U.S. Census.

Source: AACP.

¹ Denominator number is state population from 2000 U.S. Census.

² In general, state appropriations are not directly earmarked for these programs, but rather to their sponsoring institutions.

Sources: APAP, APAP Annual Report.

* Denominator number is state population from 2000 U.S. Census.

Source: ADA.

* Denominator number is state population from 2000 U.S. Census.

Sources: ADHA, AMA Health Professions.

III.  PHYSICIAN PRACTICE LOCATION

The following tables examine in-state physician practice location from two different vantage points: (1) of all physicians who were trained (went to medical school or received their most recent GME training) in the state between 1975 and 1995, and (2) of all physicians who are now practicing in the state, regardless of where they were trained.  Complied from the American Medical Association’s 1999 Physician Masterfile by Quality Resource Systems, Inc., the data importantly illustrates to what extent physician graduates practice in many of the state’s small towns, using the rural-urban continuum developed by the U.S. Department of Agriculture.

Practice location (URBAN/ RURAL) of physicians who received their ALLOPATHIC medical school training in NEW YORK between 1975 and 1995.

¹ 1995 Rural/Urban Continuum Codes for Metro and Nonmetro Counties.  Margaret A. Butler and Calvin L. Beale. Agriculture and Rural Economy Division, Economic Research Service, U.S. Department of Agriculture.

Codes # 00-03 indicate metropolitan counties:      

00: Central counties of metro areas of 1 million or more

01: Fringe counties of metro areas of 1 million or more

02: Counties with metro areas of 250,000 - 1 million

03: Counties in metro areas of less than 250,000

NA: Not Applicable; no counties in the state are in the R/U Continuum Code

Codes # 04-09 indicate non-metropolitan counties:

04: Urban population of 20,000 or more, adjacent to metro area

05: Urban population of 20,000 or more, not adjacent to metro area

06: Urban population of 2,500-19,999, adjacent to metro area

07: Urban population of 2,500-19,999, not adjacent to metro area

08: Completely rural (no place w population > 2,500), adjacent to metro area

09: Completely rural (no place w population > 2,500), not adjacent to metro area

Practice location (URBAN/ RURAL) of physicians who received their most recent GME training in NEW YORK between 1978 and 1998.

¹  1995 Rural/Urban Continuum Codes for Metro and Nonmetro Counties.  Margaret A. Butler and Calvin L. Beale.  Agriculture and Rural Economy Division, Economic Research Service, U.S. Department of Agriculture.

Codes # 00-03 indicate metropolitan counties:

00: Central counties of metro areas of 1 million or more

01: Fringe counties of metro areas of 1 million or more

02: Counties with metro areas of 250,000 - 1 million

03: Counties in metro areas of less than 250,000

Codes # 04-09 indicate non-metropolitan counties:

04: Urban population of 20,000 or more, adjacent to metro area

05: Urban population of 20,000 or more, not adjacent to metro area

06: Urban population of 2,500-19,999, adjacent to metro area

07: Urban population of 2,500-19,999, not adjacent to metro area

08: Completely rural (no place w population > 2,500), adjacent to metro area

09: Completely rural (no place w population > 2,500), not adjacent to metro area

NA: Not Applicable; no counties in the state are in the R/U Continuum Code.

IV.  LICENSURE AND REGULATION OF PRACTICE

States are responsible for regulating the practice of health professions by licensing each provider, determining the scope of practice of each provider type and developing practice guidelines for each profession.  The tables below illustrate the licensure requirements for each of the health professions covered in this study as well as additional information on recent expansions in scope of practice or other novel regulatory measures taken by the state.

Sources: State licensing board, HPTS.

Source: State licensing board.

Sources: State licensing board, AANA, ACNM, Pearson “Annual Legislative Update”, HPTS.

Source: State licensing board.

Source: State licensing board.

Source: State licensing board, ADHA.

Glossary of Acronyms

CNM: Certified nurse midwife.

CRNA: Certified registered nurse anesthetist.

NP: Nurse practitioner.

States have the challenge of not only helping to create an adequate supply of health professionals in the state, but also ensuring that those health professionals are distributed evenly throughout the state.  Various programs and incentives are used by states to encourage providers to practice in rural and other underserved areas.  The tables in this section describe New York’s programs as well as the perceived effectiveness of these programs.

RECRUITMENT/ RETENTION INITIATIVES

Source: State health officials.

New York uses focused admissions and stipends for students in rural or underserved areas as recruitment strategies for physicians.

LOAN REPAYMENT/ SCHOLARSHIP PROGRAMS *

* Includes only state-funded programs which require a service obligation in an underserved area.  (NHSC state loan repayment programs are included since the state provides funding.)

N/A* = Data is not applicable

Source: State health officials.

WORKFORCE PLANNING ACTIVITIES*

* One state health official supplied these responses. Therefore, data may be limited and may not accurately reflect all current workforce-planning activities in the state.

New York collects supply data and produces studies and evaluations for all the major health professions.

The following abstracts describe several of New York’s recent endeavors to understand and describe the status of the state’s current health care workforce.

All-Payor (Private Payor) Funding

New York is one of two states that require all-payors to contribute to graduate medical education.  The state created the “Professional Education Pool” through which funding for graduate medical education is collected and distributed. [1]   The amount of money in the Professional Education Pool is quite substantial, $670 million in 2001, but will be reduced annually until 2003 when the Legislature will re-examine the pool due to a sunset clause in the legislation.  New York requires all payors to contribute to the fund, including Blue Cross and Blue Shield, commercial insurers, health maintenance organizations (non-Medicaid and non-Medicare), businesses, self-insured funds, and third party administrators. 

Payors can make payments two ways.  First, the payor can voluntarily contribute directly to the fund based on an assessment on per covered life of the individuals or families covered by the plan.  If the payor does not make the contribution directly to the fund, the payor will be assessed a surcharge on each payment for inpatient hospital services.  The surcharge is based on a regionally determined equivalent assessment of inpatient costs plus a 24 percent differential.  The hospital then sends the surcharge to the commissioner.  The Professional Education Pool monies are distributed to teaching hospitals on a monthly basis according to the hospital’s adjusted share of a region’s total GME spending.  In addition, $54 million is distributed to teaching hospitals that meet specific training goals, such as increasing the proportion of primary care residencies and increasing the number of residents in underserved areas and ambulatory care settings.  New York’s statute also includes monetary penalty provisions if the private payor failed to contribute to the fund. 

Graduate Medical Education Reform Incentive Pool

The Graduate Medical Education Incentive Pool carves out ten percent of the funds from the Professional Education Pool to encourage hospitals to support GME reform initiatives. Rather than relying on statewide solutions for GME reform, the program allows variation in different geographic regions. The goals of the GME Incentive Pool are to 1) reduce the number of residency positions and programs; 2) increase training in primary care; 3) maintain the quality of the education program; 4) increase minority participation; 5) increase training in ambulatory settings for primary care physicians; 6) retain primary care graduates to remain and practice in New York state; and 7) to increase training in rural, urban, and underserved communities.

http://www.health.state.ny.us/nysdoh/gme/main.htm

Studies

The Health Care Workforce in New York City, 2001: Trends in the Supply and Demand For Health Workers in New York City

The Center for Health Workforce Studies, School of Public Health, University of Albany, September 2001

The third annual report on health workforce trends in New York City examines the health workforce by setting, sector, and occupation using data sources, interviews and various studies.  Specifically, the report looks at the rate of growth of the health care workforce, hospital employment trends and certificate of need approvals (CON) the supply by occupation, trends in nursing education, and the demand for health care workers in different settings.

The paper noted that the health industry is experiencing significant worker shortages and nurses and pharmacists are among the most difficult to recruit occupations at public hospitals. The report suggests that some of the factors contributing to the shortage of registered nurses (RNs) are the decline of RN graduates in the city, the aging of the existing workforce, and the growing demand for nurses in other settings.

The Supply and Distribution of Primary Care Nurse Practitioners in New York State

The Center for Health Workforce Studies, School of Public Health, University of Albany, August 2001

This report looks at the supply and distribution of primary care nurse practitioners (NPs) in New York State. The study used survey responses from 6039 actively practicing patient care NPs to break down supply and distribution by specialty and location.

Meeting Future Nursing Needs of New Yorkers: A Study of Registered Nursing in New York State

Center for Health Workforce Studies-University of Albany, May 2000

This study of the registered nurse (RN) workforce in the state found the number of nursing graduates has been declining steadily and there is likely to a be a growing shortage of RNs in the state in the next few years. The Center suggests that 1) RN graduations from nursing schools be increased moderately; 2) continuing education programs for RNs are critical given the changes in medical intervention; and 3) clinical training or new registered nurses should be expanded.

Trends in Nursing Education in New York State, 1991-2002

Center for Health Workforce Studies-University of Albany, April 2001

The Center for Health Workforce Studies surveyed registered nursing education programs in the state.  It found that RN production in the state had declined steadily from 1996 to 2000, and that the number of graduates is expected to remain the same in 2001. The survey found that associate degree nurses had decreased by nearly 32% while the production of bachelor degree nurses had decreased by 11% in a four-year period.

Trends in Registered Nursing Graduations in New York, 1996-2001

Center for Health Workforce Studies-University of Albany, April 2002

The Center surveyed registered nurse education programs in 2001. According to the report, the number of RNs graduating in New York State declined for the fifth straight year.  Every region in the state had fewer RN graduations in 2001 than in 1996. The study further notes that the number of RN graduates projected for 2003 is unlikely to be sufficient to meet the demand for registered nurses despite a projected increase in the number of graduates.   

Residency Training Outcomes by Specialty in 2000 for New York State

A Summary of Response to the 2000 NYS Resident Exit Survey

Center for Health Workforce Studies-University of Albany, 2000

This report summarizes the key findings from the Center's annual survey of all physicians completing a residency or fellowship training program in the state. The study found that the overall job market for new physicians in the state was good.  Only 5% of respondents who had actively searched had not received any job offers at the time of the survey. The study also found that demand for primary care physicians is lower than demand for non primary care physicians and that there are significant differences in the job market for different specialties. Most of the respondents were remaining in New York to begin practice.

Profile of New York State Physicians

Center for Health Workforce Studies-University of Albany, April 2001

This report provides data on primary care physicians, obstetricians/gynecologists, and psychiatrists in the state. It includes data on the absolute number of physicians and full-time equivalents in each specialty from 1995 to 1999, the number of physicians per 100,000 population in each specialty, and age and race/ethnicity profiles of physicians in each geographic area.

Resolving New York’s Nursing Shortage: Recommendations for Addressing the Nursing Shortage in New York State

A Report from the Assembly Minority Nursing Shortage Task Force, August 2001

The task force was assembled in March of 2001 and charged with collecting information on the shortage of practicing nurses, hearing testimony from concerned parties adversely effected by the shortage, and developing a set of recommendation to address the shortage. The Task Force found that the nursing shortage is having an effect on the quality and availability of care in New York. Participants noted that Hospitals have cancelled scheduled surgeries and diverted ambulances, nursing homes have reported closing beds, and home care agencies are unable to accept referrals due to the current shortage. Nurses complained of poor working conditions, being forced to work mandatory overtimes, lack of communication between nurses and administrators, burdensome paperwork, and low salaries.  The task force recommended 1) making scholarships and stipends available to nursing students; 2) bolstering nursing education programs; 3) supporting a coordinated campaign to interest young people in nursing and health careers; 4) collecting data on the breadth and depth of the shortage; and 5) implementing measures designed to improve working conditions and retain nurses.

A Report on the Supply and Demand for Registered Nurses in New York State

New York State Nurses Association, 2000

The report found that the current demand for registered nurses in the state is greater than the supply, and that the supply of RNs is likely to decrease over the next few years due to the recent decreases in enrollments in nursing programs. It also noted that there is a lack of regularly collected data on RNs and their employment patterns. The report concluded that more data was needed to assess the workforce needs and that steps should be taken to increase the overall supply of RNs.

Protecting the Public: The Future of Nursing in New York State

New York State Board of Regents: Blue Ribbon Task Force on the Future of Nursing, September 2001

This report describes the nursing shortage in New York and defines the relationship between nursing education an the supply of nurses. The task force sites the aging workforce, under-representation of minorities, more career opportunities for women, inaccurate projections of need, the workplace environment, and the aging population as factors affecting the current shortage. The task force recommended using initiatives to retain the current nursing workforce, undertaking recruitment efforts to expand the workforce, providing additional academic and financial support systems to increase the number of nursing school graduates, and developing reliable central source of data on the nursing workforce to address the current nursing shortage.

HRSA State Health Workforce Profile

Bureau of Health Professions, December 2000

The State Health Workforce Profiles provide current data on the supply, demand, distribution, education and use of health care professionals in each state. Each state profile has an overview of the health status of state residents and health services within the state. In addition the profiles have breakdowns of health care employment by place of work and profession.

http://bhpr.hrsa.gov/healthworkforce/profiles/default.htm

VII.  POLICY ANALYSIS

Organizations with Significant Involvement in Health Workforce Analysis/Development

• Healthcare Association of New York State
• New York State Nurses Association
• New York State Department of Health
• Legislature
• Center for Health Workforce Studies-SUNY, Albany
• New York State Board of Regents

Evidence of Collaboration: Minimum to Moderate (largely associated with workforce recruitment and retraining, and workforce data assimilation)

Although New York is largely metropolitan, the upper portion of the state has a significant rural population.  The state’s minority and ethnic population accounts for over a third of New York’s total population.

By various indicators, New York residents enjoy higher access to health care services than most states.  A larger proportion of residents visit a physician and dentist, and the proportion of the population living in primary care and dental health professional shortage areas (HPSAs) is below the national average.  Also, the overall ratio of the number of most health professionals to the population is much higher in New York than the U.S. as a whole.  There is also a smaller percent of the population without health insurance than the U.S. as a whole, and the percent is shrinking.

New York state government has a long history of addressing state health workforce issues in the context of larger health system changes and reforms.  Public third party payment rates to the state’s hospital and health care system historically have been centrally regulated by the state.  In that context, no significant change in Medicaid payment rates to physicians and dentists appear to have occurred in the past decade.  Since 1997, however, payment rates have been deregulated in favor of market-based negotiation. 

The state also has numerous grant and loan programs intended to improve the supply of health professionals in primary care and long-term care disciplines and in rural and indigent underserved communities.  State officials rank their initiatives to recruit medical students from rural or underserved areas and state support for health professions education in underserved communities as having a major impact on recruiting and retaining health professionals to needy areas of the state.

New York devotes significant attention to better understanding its health workforce needs through collection and analysis of data on the state’s health professions in training and practice.  The Center for Health Workforce Studies at the State University of New York in Albany routinely provides state officials and others respected reports and analyses of physician and nurse supply in the state.  The state hospital and nursing associations, as well as the state’s major health professional licensing boards, also regularly collect workforce data on members or licensees that is made available to state policymakers.

A recent economic recession and growing shortages of nurses and other health professionals in the state have focused attention on efforts to establish a major new state-funded health workforce retraining initiative.  State-supported health worker retraining was originally established in the early 1990s.  The latest initiative is supported by a coalition of hospitals, nursing homes, nurse executives, home care agencies and adult care facilities.  Health care workers in these settings are heavily unionized, and such unions have significant influence on state policymakers.  In 2001, the coalition called for new state funds to support 1) improvements in health care staff wages and benefits, 2) expansion and renewal of scholarships, grants and public education programs that offer financial incentives to enter or re-enter the health care field, and 3) promotion of health care as an attractive career.   

In early 2002, the governor’s proposed $3 billion health care plan—approved by the Legislature and endorsed by the state’s powerful hospital union—increases salaries for health care employees and restores some reductions in Medicaid services that were previously proposed.  Pharmacists who provide drugs to poor seniors will see a loss of $25 million in Medicaid funds--$175 million less than originally proposed by the governor.  The plan also provides $80 million in grants to hospitals, nursing homes and other qualified agencies for recruitment, retention and training of health care workers, and awards $28 million for various primary care initiatives and projects.  In addition, the budget replenishes a fund to help cover large malpractice claims against physicians.  Physicians in New York face sharp increases in 2002 in their malpractice insurance premiums.  Nationwide, annual malpractice insurance rates have increased an average of 30 percent.   In his 2002 state-of-the-state address, the governor also announced plans to have legislation introduced that would support increased staffing in various health care facilities. 

Physicians

New York has the second highest proportion of practicing physicians per 100,000 population of any state in the country.  However, despite such overall abundance of physicians statewide, there are many areas of the state—particularly rural in nature—where supply of specialty and primary care physicians is low and access to care is limited.  In 1999, the Legislature authorized the state Board of Regents to extend a waiver allowing physicians with alien citizenship who are completing a service obligation under an approved VISA waiver program to work in medically underserved areas of the state.

New York is a major producer of physicians.  The state has 13 medical schools and over 100 teaching hospitals that graduate over 1,900 physicians a year and house over 10 percent of all the medical students in the country.  New York also has more medical residents per 100,000 population than any other state.  In 1999-2000, the state had over 14,700 residents training in more than 1,100 programs.

With this level of production, the state fares well in retaining a significant portion of its graduates.  About three-fourths of currently practicing physicians completed their most recent GME in the state.  In 2000, just over half of graduating residents report remaining in state to practice.  Of those, 17 percent report entering practice in a HPSA and 7 percent in some rural area of the state.

State support for medical schools is relatively small and declining.  State appropriations to the four public schools dropped significantly in the 1980s and 1990s.  Despite a decline in state support for family medicine residency programs, New York has been a leader in encouraging graduate training in primary care.  The state’s Council on Graduate Medical Education, located in the Department of Health, first called for training of primary care residents in ambulatory settings in the mid 1980s.  In 1992, the Legislature, based on the Council’s recommendation, passed a law to weight primary care more heavily in non-Medicare, state indirect medical education payments to teaching hospitals. 

In 1996, another law instituted a new system for financing graduate medical education that includes an assessment on insurers and purchasers of health care and distributes payments by region.  The state Medicaid agency now provides over $800 million annually in GME payments, which continue to go directly to teaching programs under managed care.  The 1996 law also called for the competitive distribution of up to $54 million annually to approved graduate training consortia and hospitals based on state workforce goals including increasing the proportion of residents trained in primary care.  Presently, in its fourth year of operation, the physician training incentive pool is funded at about $25 million annually.  Funds are distributed to encourage an increase in the number of underrepresented minorities and training in ambulatory settings.

A 2000 state law required the Department of Health to establish a system for collecting various information on the state’s 72,000 licensed physicians that would be available for public review.  In early 2002, the state launched a website containing information on physician criminal convictions, disciplinary actions, educational history, location of primary practice, hospital privileges and malpractice judgments.  The same information is available by calling a toll-free telephone number.

Nursing

With over 300,000 licensed nurses, New York has the second largest population of nurses of any state in the nation.  Despite this abundance of nurses, there are indications of a growing nursing shortage.  Recent surveys find that three-quarters of the state’s hospitals report nursing shortages, particularly outside of New York City.  Vacancies for registered nurses reportedly take an average of three months to fill.  There are also reports that up to 19 percent of licensed nurses in the state are employed outside of nursing.  On average, the state’s more than 100 nursing schools have seen a continuous drop in both enrollment and graduations over the last five to six years.  Several schools report inadequate training capacity as the major problem, particularly the lack of qualified faculty.  Reports issued in the past two years by the Legislature, state hospital and nursing associations, state Board of Regents, and others provide documentation as well as recommendations to address the problem.  However, there remains concern about the lack of a reliable central source of data and analysis on nursing supply and demand in the state.  The nursing association’s focus for addressing the problem is on retention and finding ways to improve working conditions for nurses.

The state has been slow to provide support to address the shortage problem.  Legislation in 2001 calling for a limitation on mandatory overtime for nurses, creation of a minimum nurse staffing formula, whistleblower protection, creation of a statewide nurse staffing center, and establishment of a state nursing scholarship program await lawmaker action in 2002 (as of April 2002).

Dentists and Pharmacists

New York has focused much less attention on the dental and pharmacy workforce. 

As elsewhere, the shortage of dentists who serve Medicaid recipients is a problem in New York.  Concerns by dentists over low Medicaid payment rates resulted in a 2000 suit of the state by the state dental association.  As a result of the suit, dentists won the right to receive incremental Medicaid rate increases.

The state has relatively liberal licensing requirements for dentists that allow larger numbers of foreign trained and out-of-state dentists to practice in New York.  However, shortages of dentists are becoming more acute in rural areas of the state.  Fewer younger dentists are choosing buy the rural practices of a growing number of older dentists facing retirement.  A 2001 rural health summit in New York called on the state to develop more incentives to get dentists to locate to rural communities and give dental hygienists in rural areas the authority to bill Medicaid directly.  The state does not currently have a dentist loan repayment program, although proposed 2002 legislation would establish such a program.  There are reports of regional shortages of hygienists despite the fact that New York’s 10 oral hygiene schools are spread across the state.   

Reports of a shortage of pharmacists, particularly in smaller rural hospitals, are increasing.   Offers of higher compensation and better hours from a growing presence of chain drug stores is luring pharmacists from hospitals.  Consequently, many hospitals reportedly are now having to contract more for pharmacist services.

New York is one of two states receiving a federal demonstration grant in late 2001 to help organizations that participate in the 340B drug discount program to find creative ways to reduce administrative costs and improve access to prescription drugs for safety net patient.  The 340B program requires drug manufacturers to sell drugs to specified safety-net providers at a discount rate.  A group of 11 community health centers in Ticonderoga uses grant funds to contract with multiple pharmacies to make medications and pharmacy services more available to indigent patients served by the health centers.

Data Sources

Workforce Supply and Demand

American Association of Retired Persons, Public Policy Institute (AARP). Reforming the Health Care System: State Profiles 2001.  (Washington, DC: 2002).

Bureau of Primary Health Care, Division of Shortage Designation (BPHC-DSD). Selected Statistics on Health Professional Shortage Areas (Bethesda, MD: December 2001).

Bureau of Primary Health Care, National Health Service Corps (BPHC-NHSC). National Health Service Corps Field Strength: Fiscal Year 2001 (Bethesda, MD: March 2002).

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report: State Specific Prevalence of Selected Health Behaviors, by Race and Ethnicity—Behavioral Risk Factor Surveillance System, 1997.  (Atlanta, GA: March 24, 2000) Vol. 49, No. SS-2.

Health Resources and Services Administration, Bureau of Health Professions, National Center for Health Workforce Information and Analysis (HRSA-BHPr). State Health Workforce Profiles (Bethesda, MD: December 2000).

Health Resources and Services Administration, Bureau of Health Professions, Division of Nursing (HRSA-BHPr). The Registered Nurse Population, March 2000: Findings from the National Sample Survey of Registered Nurses (Rockville, MD: February 2002).

Kaiser Family Foundation, Kaiser Commission on Medicaid and the Uninsured (KFF). Health Insurance Coverage in America: 1999 Data Update (Palo Alto, CA: January 2001).

National Conference of State Legislatures, Health Policy Tracking Service (HPTS).

Personal conversations with HCFA regional office officials.

S. Norton and S. Zuckerman. “Trends in Medicaid Physician Fees” Health Affairs. 19(4), July/August 2000.

State Medicaid programs (data from NCSL survey).

United States Department of Commerce, U.S. Census Bureau.

United States General Accounting Office (GAO). Oral Health: Dental Disease is a Chronic Problem Among Low-Income Populations.  (Washington, DC: April 2000) GAO/HEHS-00-72.

Health Professions Education

American Academy of Family Physicians (AAFP)

American Academy of Family Physicians. State Legislation and Funding for Family Practice Programs. (Washington, DC).

American Association of Colleges of Nursing (AACN)

American Association of Colleges of Osteopathic Medicine (AACOM). Annual Statistical Report. (Chevy Chase, MD).

American Association of Colleges of Pharmacy (AACP). Profile of Pharmacy Students. (Alexandria, VA).

American Dental Association (ADA)

American Dental Association. 1997-1998 Survey of Predoctoral Dental Educational Institutions. (Washington, DC).

American Dental Hygienist Association (ADHA)

American Medical Association (AMA). Health Professions Career and Education Directory.

American Medical Association. State-level Data for Accredited Graduate Medical Education Programs in the U.S.: 2000-2001. (Washington, DC: 2002)

Association of American Medical Colleges (AAMC)

Association of American Medical Colleges.  Institutional Goals Ranking Report. (AAMC website).

Association of Physician Assistant Programs (APAP).

Association of Physician Assistant Programs. Seventeenth Annual Report on Physician Assistant Educational Programs in the United States, 2000-2001. (Loretto, PA: 2001).

Barzansky B. et al., “Educational Programs in U.S. Medical Schools, 2000-2001” JAMA. 286(9), September 5, 2001.

Henderson, T., Funding of Graduate Medical Education by State Medicaid Programs, prepared for the Association of American Medical Colleges, April 1999.

Kahn N. et al., “Entry of U.S. Medical School Graduates into Family Practice Residencies: 1997-1998 and 3-year Summary” Family Medicine. 30(8), September 1998.

Kahn N. et al., “Entry of U.S. Medical School Graduates into Family Practice Residencies: 1996-1997 and 3-year Summary” Family Medicine. 29(8), September 1997.

Kahn N. et al., “Entry of U.S. Medical School Graduates into Family Practice Residencies: 1995-1996 and 3-year Summary” Family Medicine. 28(8), September 1996.

National League for Nursing (NLN)

Oliver T. et al., State Variations in Medicare Payments for Graduate Medical Education in California and Other States, prepared for the California HealthCare Foundation. (Data from the Health Care Financing

Administration, compiled by the Congressional Research Service.)

Pugno P. et al.. “Entry of U.S. Medical School Graduates into Family Practice Residencies: 1999-2000 and 3-year Summary” Family Medicine. 32(8), September 2000.

Pugno P. et al.. “Entry of U.S. Medical School Graduates into Family Practice Residencies: 2000-2001 and 3-year Summary” Family Medicine. 33(8), September 2001.

Schmittling G. et al. “Entry of U.S. Medical School Graduates into Family Practice Residencies: 1998-1999 and 3-year Summary” Family Medicine. 31(8), September 1999.

State higher education coordinating board/university board of trustees (data from NCSL survey).

Physician Practice Location

1999 American Medical Association Physician Masterfile. Computations were performed by Quality Resource Systems, Inc. of Fairfax, Virginia.

Licensure and Regulation of Practice

American Association of Nurse Anesthetists (AANA)

American College of Nurse Midwives (ACNM). Direct Entry Midwifery: A Summary of State Laws and Regulations. (Washington, DC: 1999).

American College of Nurse Midwives. Nurse-Midwifery Today: A Handbook of State Laws and Regulations. (Washington, DC: 1999).

American Dental Hygienist Association

National Conference of State Legislatures, Health Policy Tracking Service.

Pearson L., editor.  “Annual Legislative Update: How Each State Stands on Legislative Issues Affecting

Advanced Nursing Practice” The Nurse Practitioner. 25(1), January 2001.

State licensing boards (NCSL survey).

Improving the Practice Environment

State health officials (NCSL survey).