New York State Health Professionals
in Health Professional Shortage Areas:
A Report to the New York State
Area Health Education Centers System
Submitted by
May 2004
Institute for Urban Family Health
Neil Calman, M.D.
President and CEO
Diane Hauser, M.P.A.
Project Manager
16 East 16th Street
New York, New York 10003
Phone:
Fax:
Website:
(212) 633-0800
(212) 691-4610
Institute2000.org
Table of Contents
Executive Summary ............................................................................................... i
Overview of the Report ......................................................................................... 1
Physicians in New York State ............................................................................... 5
Nurse Practitioners in New York State ................................................................ 21
Certified Nurse Midwives in New York State ....................................................... 25
Certified Registered Nurse Anesthetists in New York State ................................ 30
Recent Dental Graduates in New York State ...................................................... 37
Tables
2.1
Patient Care Physicians in the U.S. and Selected States (2000) ..............................6
2.2
Physicians in New York State in 2000 by AHEC Region and HPSAs ...................7
2.3
Physicians in New York State AHECs per population (2000) ................................8
2.4
Primary Care Physicians in New York State AHEC Regions (2000) .....................8
2.5
Primary Care Physicians in New York State HPSAs (2000) ...................................9
2.6
Most Populated Non-Primary Care Specialties in
New York State HPSAs (2000) ...............................................................................9
2.7
2000 Physicians in New York State AHECs by Race/Ethnicity ...........................13
2.8
Physicians Practicing in New York State in 2000 Who Are Graduates of
New York State Medical Schools ..........................................................................16
2.9
Primary Care Physicians Practicing in New York State in 2000 Who Are
Graduates of New York State Medical Schools ....................................................17
2.10
Medical Schools Graduating the Highest Number of New York State
Physicians Practicing in Non-Metropolitan HPSAs in 2000 .................................18
2.11
Medical Schools Graduating the Highest Number of New York State
Physicians Practicing in Metropolitan HPSAs in 2000 .........................................18
3.1
Primary Care Nurse Practitioners in Practice in the U.S. and Selected States
in 1999 ...................................................................................................................22
3.2
Primary Care Nurse Practitioners in New York State AHEC Regions
in 1999 ...................................................................................................................23
3.3
Primary Care Nurse Practitioners in New York State HPSAs in 1999..................23
3.4
Primary Care Nurse Practitioners in New York State Metropolitan and
Non-Metropolitan HPSAs in 1999 by Specialty ....................................................24
4.1
Certified Nurse Midwives in Practice in the U.S. and Selected States
in 2001 ...................................................................................................................26
4.2
Certified Nurse Midwives in New York State AHEC Regions in 2001 ................26
Tables (Cont.)
4.3
Certified Nurse Midwives in New York State AHECs
by Race/Ethnicity (2001) .......................................................................................28
4.4
Number of CNMs in NYS AHEC Regions in 2001 by Year of Certification .......29
5.1
Certified Registered Nurse Anesthetists in Practice in the U.S.
and Selected States in 2001....................................................................................31
5.2
CRNAs in New York State AHEC Regions in 2001 by Age ................................32
5.3
CRNAs in Metropolitan and Non-Metropolitan
New York State HPSAs by Age ............................................................................33
5.4
CRNAs in New York State by Number of Years in Practice (2001).....................35
5.5
New York State CRNAs in HPSA Locations by Years in Practice (2001) ...........35
6.1
Recent Dental Graduates (1993-1999) in Practice in the U.S.
and Selected States in 2001....................................................................................35
6.2
Recent Dental Graduates Practicing in New York AHEC Regions in 2001
by Year of Dental School Graduation ....................................................................39
6.3
Total New York State Dentists and New Entrants by AHEC Region ...................41
6.4
Dentists in New York State AHECs in 2001 by Gender and
Year of Graduation ................................................................................................41
6.5
Primary Occupation of Recent Dental Graduates in New York State in 2001 ......42
6.6
Recent Dental Graduates Practicing in New York State AHEC Regions
in 2001 by Specialty...............................................................................................43
Figures
1.1
New York State AHEC Regions ..............................................................................3
2.1
Percentage of All Physicians and HPSA Physicians That Are Female in New
York State AHEC Regions in 2000 .......................................................................10
2.2
Percentage of All Primary Care Physicians and HPSA Primary Care Physicians
That Are Female in New York State AHEC Regions in 2000 ..............................11
Figures (Cont.)
2.3
Percentage of All 2000 Physicians and Primary Care Physicians that are IMGs
by New York State AHEC Region ........................................................................12
2.4
Percentage of 2000 USMG and IMG New York State Physicians in HPSAs .......13
2.5
Percentage of New York State Physicians in HPSA and Non-HPSA
Locations in 2000 by Race/Ethnicity .....................................................................14
2.6
Percentage of New York State USMG and IMG Primary Care Physicians in
HPSAs in New York State in 2000 by Estimated Year of Initial Practice ............15
4.1
CNMs by AHEC Region and 2001 HPSA/Non-HPSA Work Location ...............27
4.2
Number of 2001 NYS CNMs in Metropolitan HPSAs, Non-Metropolitan
HPSAs and Non-HPSA Practice Locations by Year of Certification....................28
5.1
CRNAs in New York State AHEC Regions by 2001 HPSA/Non-HPSA
Practice Location ...................................................................................................32
5.2
Male CRNAs by AHEC Region and 2001 HPSA/Non-HPSA
Practice Location ...................................................................................................34
5.3
Female CRNAs by AHEC Region and 2001 HPSA and Non-HPSA Practice
Location .................................................................................................................34
6.1
Percentage of 1993-1999 Dental Graduates Practicing in
Dental HPSAs in 2001 ...........................................................................................40
6.2
Percentage of 1993-1999 Dental Graduates Practicing in Primary Care
HPSAs
in 2001 ...................................................................................................................40
Executive Summary
Despite an abundance of health professionals, New York State has 102 communities and
facilities designated by the federal government as health professional shortage areas
(HPSAs) due to a lack of physicians in the area (geographic HPSAs) or the existence of
economic and/or cultural and language barriers that hinder access to physicians (special
population HPSAs). Nearly 3.6 million New Yorkers reside in HPSAs and 1.8 million
are estimated to be medically underserved.
This report to the New York State Area Health Education Centers (AHEC) System
provides an analysis of the health professions workforce in New York State’s HPSA
communities. Using national data sets of practicing physicians, nurse practitioners,
certified nurse midwives, certified registered nurse anesthetists, and dentists, practice
addresses for these health professionals were identified and cross-referenced with New
York’s HPSA boundaries. Health professionals in HPSAs were quantified and relevant
characteristics, such as specialty, gender, and race/ethnicity, were analyzed where they
were available. Major findings from the study are summarized below.
Physicians

Fourteen percent of all New York State physicians practice in HPSAs.

Sixteen percent of primary care physicians in New York State practice in
HPSAs.

93.5% of New York’s HPSA physicians practice in metropolitan HPSAs;
6.5 percent practice in non-metropolitan HPSAs.

Thirty-one percent of black physicians and twenty-three percent of
Hispanic physicians in New York State practice in HPSAs.

Family physicians make up the largest proportion of primary care
physicians in non-metropolitan HPSAs; general internists make up the
largest proportion in metropolitan HPSAs.

International medical graduates practice in New York State HPSAs
(metropolitan and non-metropolitan) at higher rates than U.S. medical
graduates.

Female physicians and physicians from underrepresented minority groups
are more likely to practice in metropolitan HPSAs than in nonmetropolitan HPSAs.

Medical schools in New York State are the largest producers of physicians
practicing in New York’s HPSAs, followed by international medical
schools.
i
Nurse Practitioners

New York State has the largest primary care nurse practitioner workforce in the
country.

Twenty-six percent of nurse practitioners in New York State practice in HPSAs.

Family nurse practitioners practice in HPSAs at higher rates than nurse
practitioners in other primary care specialties and account for over 60 percent of
all nurse practitioners in non-metropolitan HPSAs.
Certified Nurse Midwives

Over one in four certified nurse midwives (CNMs) in New York State practice in
a HPSA.

Sixty percent of CNMs in New York State practice in the New York City
metropolitan region, as do eighty percent of CNMs practicing in HPSA.

New York State’s CNM workforce is more diverse than the national CNM
workforce, but is still far from representative of the population.
Certified Registered Nurse Anesthetists

New York State has a smaller workforce of certified registered nurse anesthetists
(CRNAs) than other large states.

Nearly twenty percent of CRNAs in New York State practice in HPSAs.

Male CRNAs in New York State are disproportionately distributed in nonmetropolitan HPSAs and female CRNAs are disproportionately distributed in
metropolitan HPSAs.
Dentists

Seven percent of recently graduated dentists (1993-1999) in New York State
practice in dental HPSAs.

Six percent of dentists in New York State practice in primary medical HPSAs.

Some New York State AHEC regions have increasing numbers of recent dental
graduates practicing in 2001 and others have diminishing numbers.

Some New York State AHEC regions have no recent graduate dentists practicing
in one or more dental specialties, such as oral surgery and periodontics.
ii
Section 1. Overview of the Report
1.1
Purpose of the Report
The goal of this study is to determine the number of health professionals practicing in
New York State’s federally designated primary care and dental health professional
shortage areas (HPSAs). The distribution of physicians, dentists, nurse practitioners,
certified nurse midwives and certified registered nurse anesthetists in the state were
analyzed. The study also analyses certain characteristics of health professionals in
shortage areas in order to better describe the workforce in HPSAs and to identify issues
that may be useful in targeting recruitment efforts.
Parallel studies have examined these data on the national level. One study presents
similar data for health professionals throughout the United States.1 A second study
analyzes U.S. physicians in all specialties with respect to practice in HPSAs.2
Federal HPSA designations have been used to identify health professional shortages and
direct resources to underserved communities for over 30 years. Criteria for designation
of primary care geographic HPSAs include a population-to-physician ratio that exceeds
3,500:1 (3,000 where high needs are indicated). Dental HPSA criteria include a
population-to dentist ratio that exceeds 5,000:1 (4,000 in areas of high need). Special
population HPSA designations are available to communities that experience barriers to
health care due to economic, linguistic, and/or cultural factors. Public facilities, such a
prisons and hospitals that experience health professional shortages also can qualify as
HPSAs. Recent changes in regulation have expanded eligible facilities to include
community health centers.
Approximately 3,000 HPSAs are designated nationally by the Health Resources and
Services Administration’s Bureau of Health Professions, comprising an underserved
population estimated at 30 million Americans. HPSA communities are able to
participate in several Federal programs designed to attract health professionals, including
serving as practice sites for the National Health Service Corps, Medicare bonus
payments, and visa waiver programs for physicians who are not U.S. citizens.
New York State utilizes federally designated HPSAs, as well as some additional criteria,
in several state-sponsored scholarship and loan repayment programs available to health
professionals who fulfill service obligations in shortage areas. Visa waivers for
physicians practicing in New York who are not U.S. citizens or permanent residents are
also tied to practice in shortage areas. New York is one of the few states that formalizes
this process through the granting of limited three-year medical licenses. A similar policy
applies to dentists who are not U.S. citizens.
As of June 30, 2001--the time period during which the health professionals data in this
report were being gathered--New York had 102 primary care HPSA designations,
including one whole county, 57 geographic areas, 32 special population groups, and 12
facilities. The number of underserved New Yorkers was estimated at 1.7 million. The
1
Bureau of Health Professions estimates that 261 additional physicians are needed in these
communities in order to remove designations that identify the severest shortages, and 836
physicians are needed in order to achieve target ratios of one physician for every 2,000
New Yorkers.3 This report describes the current health professions workforce in New
York’s HPSAs communities using the available data.
1.2 Overview of Methods
For each of the health professions in this report, a national data file was obtained which
contains the practice addresses of active health professionals and data on other
characteristics, such as year of graduation, gender, race/ethnicity, and practice specialty.
Each data file is described in more detail in the corresponding sections of the report.
Data files maintained by the Division of Shortage Designation within HRSA’s Bureau of
Health Professions were used to identify health professional shortage areas (HPSAs)
nationally. Three separate HPSA files were obtained for use in analyzing the various
health professions: a file identifying primary medical HPSAs designated as of July 2001;
a file identifying dental HPSAs designated as of July 2001; and a file identifying primary
medical HPSAs designated as of December 1999. The 1999 file included only
geographic and low-income special population HPSAs; the 2001 HPSA files contained
all HPSA designations.
The physician data were culled from the American Medical Association’s Year-End 2000
Physician Masterfile and cross-referenced with the primary medical HPSA file from July
2001. Similarly, the data files for nurse midwives from the American College of Nurse
Midwives and for certified registered nurse anesthetists from the American Association
of Nurse Anesthetists were created in July 2001 and were cross-referenced with the
primary medical HPSA file from July 2001. The nurse practitioner data are from a
survey conducted by the American Association of Nurse Practitioners in 1999 and were
cross-referenced with the 1999 primary medical HPSA file. Finally, the dentist data file
was created using American Dental Association data from December 2001 and was
cross-referenced with both a dental HPSA file and a primary medical HPSA file from
July 2001.
HPSA boundaries are identified as whole counties or groups of census tracts. All
relevant HPSA types were used in this analysis, including single county, geographic or
service area and special population groups, except in the 1999 HPSA file as indicated
above. The addresses from the health professions data files were geocoded and crossreferenced with the HPSA file using MapInfo and SAS statistical software in order to
identify health professionals with work addresses located within HPSA boundaries, either
whole county or partial-county HPSAs.
HPSA data files identify each HPSA as “metropolitan” or “non-metropolitan.” These
categories are established using the definitions created by the United States Office of
Management and Budget. A metropolitan area includes at least one city with 50,000 or
2
more inhabitants or a Census Bureau-defined urbanized area of at least 50,000 inhabitants
and a total metropolitan population of at least 100,000 (75,000 in New England). HPSAs
that do not meet the definition of metropolitan are defined as non-metropolitan. Crosstabulations were conducted to identify health professionals as practicing in either
metropolitan or non-metropolitan HPSAs. County codes were used to identify health
professionals practicing in each of the nine New York Area Health Education Centers
System regions (described in the next section). The study findings are presented in
Sections 2 though 6 of the report.
1.3
The AHEC Program
The New York State Area Health Education Centers (AHEC) System, based at the State
University of New York at Buffalo, was established in 1998 to enhance the quality of and
access to health care, improve health care outcomes, and address the health workforce
needs of medically underserved communities and populations. This mission is
accomplished primarily through the establishment of partnerships between institutions
that train health professionals and communities in need. The New York AHEC System
is administered through nine AHEC regions (see Figure 1.)
Figure 1.
3
To assist the New York AHEC System in addressing health workforce needs, the health
professions data in this report are presented for each AHEC region, as well as for New
York State as a whole. While some AHEC regions have a mix of metropolitan and nonmetropolitan counties, some are uniformly defined. The Northern AHEC is the only
AHEC in the state that is comprised of all non-metropolitan counties. Therefore, all
HPSAs in that AHEC are non-metropolitan. The Bronx-Westchester, Brooklyn-QueenLong Island, Erie-Niagara, and Manhattan-Staten Island AHECs are comprised of
metropolitan AHECs and have only metropolitan HPSA designations. The remaining
AHEC regions have a mix of metropolitan and non-metropolitan counties.
1.4
Comment on Findings
This study found that for nurse practitioners, certified nurse midwives, and certified
registered nurse anesthetists, New York has a higher than average proportion of health
care professionals practicing in HPSAs. While this is a welcome finding, it is important
to note that the study does not measure access to the service of these health professionals.
Almost one in three New York HPSAs is designated based on the existence of economic,
cultural and/or linguistic barriers to care for a particular community. Access to health
care must be addressed through future studies.
New York State health professionals were identified using the best available national data
sets. However, there is much room for improvement. The national data sets have
varying data elements and survey response rates. These data are available at the
discretion of the national health professional organizations that conduct the surveys, and
not all requested data were provided.
New York has a number of options for obtaining current and complete data on health
professionals practicing in the state and should consider maintaining its own data set for
workforce analysis. Ensuring an adequate ratio of health care professionals to the
population is a critical component of a sound health care system. This cannot be
accomplished without appropriate data sources.
Lastly, HPSA designations were established as a mechanism for triaging scarce health
care resources and have a number of programmatic uses. Because the designation
process relies on states and communities with varying levels of resources and expertise to
initiate the effort to submit applications, HPSAs do not reflect a systematic approach to
identifying communities experiencing shortages of health professionals. There may be
communities in New York, and elsewhere, which have health professional shortages, but
have not gained HPSA designations. It is also likely that there are health professionals
practicing in communities that are not within HPSA boundaries but provide care for those
residing in HPSAs or are otherwise vulnerable to health care barriers.
It is hoped that this report stimulates continued efforts to establish and maintain highquality data on health professionals in New York State from which sound state health
policies can be developed.
4
Physicians in New York State
Background
There are 536,306 physicians and 95,125 residents and fellows classified by the
American Medical Association as non-Federal, patient care physicians.4 Approximately
nine percent, roughly 48,000, of these physicians practice in New York State, while over
14 percent of the nation’s residents and fellows train and practice in the state. New York
State is home to thirteen medical schools that graduated nearly 2,000 students in 2003.
Despite an abundance of physicians and other health professionals, New York also has
102 communities and facilities designated by the federal government as health
professional shortage areas (HPSAs) due to a lack of physicians in the area (geographic
HPSAs) or the existence of economic and/or cultural and language barriers that hinder
access to physicians (special population HPSAs). Nearly 3.6 million New Yorkers reside
in HPSAs and 1.8 million are estimated to be medically underserved. 5 This section of
the study examines the composition of the New York State physician workforce with
respect to HPSAs.
Study Methods
The New York State physician data used in this study are from the year-end 2000
Physician Masterfile of the American Medical Association (AMA). All physicians
identified as non-Federal patient care physicians who are office- or hospital-based
(exclusive of residents and fellows), as well as Federal physicians identified as working
for the Public Health Service and meeting the same criteria, were included in the analysis.
The AMA maintains records on U.S. physicians who are allopathic medical school
graduates, osteopathic medical school graduates who complete allopathic residency
programs, and graduates of international medical schools.
Physicians graduating from medical school between 1941 and 1996 were included in the
study. Physicians with an estimated initial year of practice of 2000 or later were
excluded. Initial year of practice was estimated for each physician by adding the medical
school graduation year and the number of graduate medical education years required by
the Accreditation Council for Graduate Medical Education for the physician’s specialty.
A total of 47,981 physician records in the data set had practice addresses within New
York State. Physician records that contained no address, an incomplete address, or only a
home address were not included in the study. In order to maximize the number of
physician records with corresponding practice addresses, Masterfile practice addresses
were supplemented with practice addresses from The Little Blue Book (The Little Blue
Book Companies, Avon, CT). Remaining records that contained only addresses that
5
were not identified as practice addresses were checked against the U.S. Postal Service’s
Delivery Sequence File, which codes all postal addresses by type. Practice addresses
were obtained for 89 percent of the physicians in the national data set. The addresses
were geocoded, enabling a longitude and latitude, as well as state and county codes, to be
assigned to each record.
These data were cross-referenced with a primary care HPSA file obtained from the
Health Resources and Services Administration’s Bureau of Health Professions, Division
of Shortage Designation. The physician records with addresses that fell within the
boundaries of a HPSA were coded as metropolitan or non-metropolitan HPSA
physicians. Cross-tabulations were conducted for relevant variables. Analyses of
primary care physicians include physicians indicating a primary specialty of family
practice, general practice, internal medicine, obstetrics and gynecology, and pediatrics.
In examinations of U.S. and international medical graduates, U.S. medical graduates
(USMGs) are graduates of U.S. and Canadian medical schools. International medical
graduates (IMGs) are foreign and U.S. citizen graduates of medical schools in all other
countries. The findings are described below.
Findings
New York Compared to Other States
New York, the third most populous state in the nation, has the second largest population
of practicing physicians, following California. Table 2.1 compares physician and HPSA
data for the U.S. and the five most populated states using the AMA data as described
above.
Table 2.1
Patient Care Physicians in the U.S. and Selected States (2000)
U.S.
NY
CA
FL
IL
TX
Total Physicians
534,256
47,981
64,170
31,097
23,214
31,637
Physicians in HPSAs
90,657
6,954
3,320
5,308
4,433
2,185
17%
14%
5%
17%
19%
7%
Physicians in Metropolitan HPSAs
72,802
6,503
2,804
4,433
3,744
1,720
Physicians in Non-Metropolitan HPSAs
17,855
451
516
875
689
465
Primary Care Physicians
215,519
18,102
26,228
11,746
10,003
12,632
Primary Care Physicians in HPSAs
36,593
2,825
1,682
2,014
1,886
1,052
17%
16%
6%
17%
19%
8%
Primary Care Physicians in Metropolitan HPSAs
27138
2607
1431
1630
1506
802
Primary Care Physicians in Non-Metropolitan HPSAs
9455
218
251
384
380
250
2,968
102
% Physicians in HPSAs
% Primary Care Physicians in HPSAs
# of HPSA Designations*
Estimated HPSA population*
# of medical schools**
Total Population (in millions as of 7/1/01)***
51,551,841 3,599,085
170
113
101
241
3,633,367
2,319,040
1,494,582
5,250,396
144
13
10
5
8
8
285.3
19.1
34.6
16.4
12.5
21.4
As of June 30, 2001, HRSA, BHPr, Division of Shortage Designation
**Association of American Medical Colleges and Association of American Colleges of Osteopathic Medicine ***U.S. Bureau of the Census
6
New York has the largest number of both total physicians and primary care physicians in
metropolitan HPSAs and the smallest number of both total physicians and primary care
physicians in non-metropolitan HPSAs in the large state comparison. Estimates of the
metropolitan and non-metropolitan distribution of New York’s HPSA population were
not available. Therefore, it was not possible to determine if New York’s physician
distribution in HPSAs is consistent with the HPSA population distribution. Nationally,
the HPSA population is roughly half metropolitan and half non-metropolitan.3 Twenty
percent of HPSA physicians nationwide were found to practice in non-metropolitan
HPSAs, while 6.5 percent of New York’s HPSA physicians practice in non-metropolitan
HPSAs.
Wide variations were found in the HPSA distribution of physicians among these large
states. As noted in Section 1, state comparisons of HPSA data reflect physician
shortages, as well as the level of effort made within individual states to quantify
shortages, and should be interpreted with care. New York is slightly below the national
average in terms of total and primary care physician distribution in HPSAs.
Physicians in New York
The distribution of New York’s 47,981 physicians among the state’s nine AHEC regions
is presented in Table 2.2. The population of the AHEC regions varies widely (see Table
2.3), as does the distribution of physicians. Statewide, 14 percent of all physicians
practice in primary care HPSAs, with variation of between one percent and 52 percent
among the AHEC regions.
Table 2.2
Physicians in New York State in 2000 by AHEC Region and HPSAs
AHEC
New York State
Bronx-Westchester
Brooklyn-Queens-Long Island
Catskill-Hudson
Central New York
Erie-Niagara
Hudson-Mohawk
Manhattan-Staten Island
Northern
Western New York
Total
Physicians
Physicians in HPSAs
47,981
6,954
5,671
565
16,520
1,581
2,670
355
3,076
1,211
2,511
525
2,254
11,852
522
2,905
21
2,107
272
317
*No HPSAs of this type in the AHEC region.
7
Physicians in
Metropolitan
HPSAs
6,503
565
1,581
319
1,142
525
Physicians in
Non-Metropolitan
HPSAs
451
*
*
36
69
*
9
2,107
*
255
12
*
272
62
Percentage
of Physicians
in HPSAs
14%
10%
10%
13%
39%
21%
1%
18%
52%
11%
The number of practicing physicians was compared to the population in each New York
State AHEC region (see Table 2.3). Statewide, there is approximately one practicing
physician for every 400 New Yorkers. This ratio varies between one physician for every
169 people in the Manhattan-Staten Island AHEC to one physician for every 728 people
in the Northern AHEC. These AHECs represent the two extremes; the remaining AHECs
have ratios of one physician to every 401 to 571 New Yorkers.
There is roughly one primary care physician for every 1,000 New Yorkers. The
distribution pattern of primary care physicians relative to the population is similar to that
of all physicians. The ratios range between one primary care physician for every 597
people in the Manhattan-Staten Island AHEC to one primary care physician for every
1,711 people in the Northern AHEC.
Table 2.3
Physicians in New York State AHECs per population (2000)
New York State
Bronx-Westchester AHEC
Brooklyn-Queens-Long Island AHEC
Catskill-Hudson AHEC
Central New York AHEC
Erie/Niagara AHEC
Hudson-Mohawk AHEC
Manhattan/Staten Island AHEC
Northern AHEC
Western New York Rural AHEC
1 Primary
Total
Total Primary 1 Physician Care Physician
Physicians Care Physicians for every:
for every:
47,981
18,104
398
1,054
5,671
2,192
401
1,039
16,520
6,897
454
1,088
2,670
1,126
571
1,355
3,076
1,220
529
1,333
2,511
992
464
1,175
2,254
844
475
1,269
11,852
3,353
169
597
522
222
728
1,711
2,905
1,258
530
1,223
Population
As of 7/1/01
19,084,350
2,276,446
7,500,547
1,525,598
1,626,372
1,165,260
1,071,286
2,000,382
379,921
1,538,838
Primary Care
The distribution of primary care physicians among the New York AHEC regions is
presented by specialty in Table 2.4. Thirty-eight percent of the State’s patient care
physicians practice a primary care specialty, compared to forty percent in the national
data set. Among the New York State AHEC regions, this percentage ranges from 28
percent to 43 percent.
Table 2.4.
Primary Care Physicians in New York State AHEC Regions (2000)
AHEC
New York State
Bronx-Westchester
Brooklyn-Queens-Long Island
Catskill-Hudson
Central New York
Erie-Niagara
Hudson-Mohawk
Manhattan-Staten Island
Northern
Western New York
Family
Practice
2,683
205
851
246
417
220
244
178
72
250
General
Practice
582
57
250
48
38
33
37
84
6
29
Internal ObstetricsMedicine Gynecology Pediatrics
7,989
2,698
4,152
1,049
307
574
3,069
996
1,731
407
146
279
401
159
205
394
145
200
289
124
150
1,733
619
739
75
35
34
572
167
240
8
Total
Primary
Care
18,104
2,192
6,897
1,126
1,220
992
844
3,353
222
1,258
% Physicians
in Primary
Care
38%
39%
42%
42%
40%
40%
37%
28%
43%
43%
The distribution of New York’s primary care physicians among the AHEC’s metropolitan
and non-metropolitan HPSAs is presented in Table 2.5. Pediatrics has the highest total
percentage of physicians in HPSAs at 18 percent, and obstetrics-gynecology has the
lowest at 13 percent. Internal medicine, the most populated of the primary care
specialties, has the highest overall number of physicians in HPSAs and the highest
number in metropolitan HPSAs. Family practice has the highest number of physicians
practicing in non-metropolitan HPSAs. Sixteen percent of primary care physicians
practice in HPSAs overall, slightly higher than the percentage for all physicians in New
York State.
Table 2.5
Primary Care Physicians in New York State HPSAs (2000)
AHEC
Family
Practice
NonMet
Met
General
Practice
NonMet
Met
Internal
Medicine
NonMet
Met
New York State
Bronx-Westchester
Brooklyn-Queens-Long Island
Catskill-Hudson
Central New York
Erie-Niagara
Hudson-Mohawk
Manhattan-Staten Island
348
38
70
27
79
43
5
48
98
*
*
17
23
*
5
*
81
11
28
6
11
3
0
16
8
*
*
1
1
*
0
*
1125
122
295
55
122
89
2
384
Northern
Western New York
*
38
34
19
*
6
1
5
*
56
ObstetricsGynecology
NonMet
Met
Pediatrics
NonMet
Met
Total Primary % Primary
Care
Care
Non- Physicians in
Met
Met
HPSAs
68
*
*
4
8
*
3
*
338
28
103
15
56
14
0
110
22
*
*
1
2
*
0
*
715
124
253
18
62
21
1
219
22
*
*
2
3
*
0
*
2607
323
749
121
330
170
8
777
218
*
*
25
37
*
8
*
16%
15%
11%
13%
30%
17%
2%
23%
39
14
*
12
18
1
*
17
16
1
*
129
108
40
49%
13%
*No HPSAs of this type in the AHEC region
Other Specialties in HPSAs
Physicians in specialties other than primary care also have a presence in HPSAs. The
eight most populated non-primary care specialties in New York’s metropolitan and nonmetropolitan HPSAs are presented in Table 2.6. Psychiatry was the most populated nonprimary care specialty in both metropolitan and non-metropolitan HPSAs. There were
more physicians practicing psychiatry in HPSAs than some of the primary care
specialties. Other specialties common to both types of HPSAs include anesthesiology,
diagnostic radiology, emergency medicine, general surgery, and ophthalmology.
Table 2.6
Most Populated Non-Primary CareSpecialties in New York State HPSAs (2000)
Non-Metropolitan HPSAs
Psychiatry
General Surgery
Anesthesiology
Emergency Medicine
Orthopedic Surgery
Ophthalmology
Diagnostic Radiology
Pathology
Total
25
21
17
17
16
14
12
10
9
Metropolitan HPSAs
Psychiatry
Anesthesiology
General Surgery
Cardiovascular Disease
Ophthalmology
Diagnostic Radiology
Emergency Medicine
Total
426
352
295
182
168
161
150
Neurology
137
Gender
The distribution of New York State physicians was also analyzed by gender. Figure 2.1
presents the percentage of physicians that are female in New York State and the AHEC
regions, along with the percentage of physicians in HPSAs that are female. The
exclusively metropolitan AHEC regions have a higher proportion of female physicians
than those that contain all or some non-metropolitan counties. Female physicians were
found to be overrepresented in HPSAs within the more metropolitan AHEC regions.
Female physicians were underrepresented in HPSAs among the more non-metropolitan
AHEC regions. Twenty-six percent of all physicians in New York are female and 28
percent of HPSA physicians are female.
Figure 2.1
Percentage of All Physicians and HPSA Physicians That Are Female
in New York State AHEC Regions in 2000
26%
28%
New York State
31%
Bronx-Westchester
25%
Brooklyn-Queens-Long Island
Catskill-Hudson
21%
19%
Central New York
20%
21%
Erie-Niagara
21%
22%
38%
30%
% Physicians That
Are Female
% HPSA
Physicians That
Are Female
21%
19%
Hudson-Mohawk
30%
Manhattan-Staten Island
34%
19%
18%
Northern
Western New York
18%
0%
5%
10%
15%
20%
23%
25%
30%
35%
40%
45%
50%
Figure 2.2 presents the percentage of primary care physicians that are female in New
York State, and the percent of primary care HPSA physicians that are female.
Nationally, as well as in New York State, female physicians choose primary care careers
more frequently than male physicians. This trend is reflected in the findings. Thirtythree percent of primary care physicians in New York State are female, and 37 percent of
primary care HPSA physicians are female.
10
Figure 2.2
Percentage of All Primary Care Physcians and HPSA Primary Care Physicians That Are
Female in New York State AHEC Regions in 2000
33%
New York State
37%
38%
Bronx-Westchester
46%
Brooklyn-Queens-Long
Island
32%
36%
29%
Catskill-Hudson
26%
26%
Central New York
32%
% Primary Care
Physicians That
Are Female
28%
28%
Erie-Niagara
30%
Hudson-Mohawk
% Primary Care
HPSA Physicians
That Are Female
19%
39%
Manhattan-Staten Island
42%
25%
Northern
22%
Western New York
22%
30%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Consistent with the finding for all New York State physicians, there are higher
percentages of female primary care physicians in the more metropolitan AHEC regions
with even higher percentages among metropolitan HPSA communities. Nearly half of
the primary care HPSA physicians in the Bronx-Westchester and Manhattan-Staten
Island AHECs are female.
USMGs and IMGs
Sixty-one percent of physicians practicing in New York State are graduates of U.S. or
Canadian medical schools. The remaining 39 percent are graduates of international
medical schools. Within the primary care workforce, 55 percent of physicians are U.S. or
Canadian medical graduates and 45 percent are international medical graduates. The
proportion of USMGs and IMGs among all physicians and those in the primary care
workforce in New York’s AHEC regions are presented in Figure 2.3.
In the most metropolitan AHEC regions, IMGs made up a larger proportion of the
primary care workforce than of the physician workforce as a whole. In the other AHEC
regions, IMGs were distributed equally or nearly equally in both the total physician
workforce and the primary care physician workforce.
11
Figure 2.3
Percentage of All 2000 Physicians and Primary Care Physicians that are IMGs
by New York State AHEC Region
39%
New York State
45%
41%
Bronx-Westchester
49%
Brooklyn-Queens-Long
Island
52%
58%
40%
41%
Catskill-Hudson
30%
30%
Central New York
% of total that
are IMGs
35%
33%
Erie-Niagara
% primary care
that are IMGs
26%
26%
Hudson-Mohawk
31%
Manhattan-Staten Island
38%
31%
29%
Northern
27%
27%
Western New York
0%
10%
20%
30%
40%
50%
60%
70%
In a comparison of physicians in HPSAs, IMGs were found to practice in HPSAs in
higher proportions than USMGs in all New York State AHEC regions, with the exception
of the Hudson-Mohawk AHEC (see Figure 2.4). Statewide, 13 percent of USMGs
practice in HPSAs and 17 percent of IMGs practice in HPSAs. The proportion of
primary care USMG and IMG physicians in HPSAs followed a similar distribution
pattern, although primary care physicians were slightly more likely to practice in HPSAs
statewide with 14 percent of USMGs and 18 percent of IMGs in HPSAs.
12
Figure 2.4
Percentage of 2000 USMG and IMG New York State Physicians in HPSAs
13%
17%
New York State
5%
Bronx-Westchester
17%
7%
Brooklyn-Queens-Long Island
12%
12%
16%
Catskill-Hudson
38%
42%
Central New York
20%
23%
Erie-Niagara
Hudson-Mohawk
% All USMGs in
HPSAs
% All IMGs in
HPSAs
1%
1%
16%
Manhattan-Staten Island
22%
49%
Northern
8%
Western New York
0%
59%
18%
10%
20%
30%
40%
50%
60%
70%
Race/Ethnicity
Self-reported race or ethnicity data were available for 71 percent of New York State
physicians. Based on analysis which excludes physician records in which race or
ethnicity was not known, 71 percent of physicians in New York State are non-Hispanic
white, 16 percent are Asian/Pacific Islander, four percent are non-Hispanic black, four
percent are Hispanic, four percent are identified as “other,” and less than one percent are
Native American/Alaskan Native.
Table 2.7
Physicians in New York State AHECs by Race/Ethnicity (2000)
Hispanic
American
Indian/
Alaskan
Native
Other
Missing
White, NonHispanic
Black, NonHispanic
Asian/
Pacific
Islander
New York State
24,080
1,512
5,658
1,338
14
1,229
14,150
8%
Bronx-Westchester
2,652
254
673
236
1
148
1,707
12%
Brooklyn-Queens-Long Island
7,445
707
2,298
487
4
500
5,079
10%
Catskill-Hudson
1,374
41
359
39
0
78
779
4%
Central New York
1,705
49
343
65
1
76
837
5%
Erie-Niagara
1,200
38
321
48
1
60
843
5%
Hudson-Mohawk
1,289
28
217
38
0
38
644
4%
Manhattan-Staten Island
6,411
349
1,103
385
4
234
3,366
9%
AHEC
Northern
Western New York
% Underrepresented
Minority*
282
9
52
6
0
17
156
4%
1,722
37
292
34
3
78
739
3%
*Black, non-Hispanic; Hispanic; and American Indian/Alaskan Native
13
Table 2.7 presents physician race or ethnicity data for the nine New York State AHEC
regions. The three AHECs in the New York City area have the most diverse physician
workforces. The Bronx-Westchester AHEC had the highest percentage of practicing
physicians from underrepresented minority groups. The Western New York AHEC had
the smallest proportion of underrepresented minority physicians.
The percentage of physicians practicing in New York’s non-metropolitan HPSAs was
consistently small among all racial and ethnic groups, ranging from less than one percent
to two percent. Differences were seen in the percentage of physicians choosing to
practice in metropolitan HPSAs. Non-Hispanic black physicians were the most likely to
practice in metropolitan HPSAs; nearly one in three black physicians practice in
metropolitan HPSAs. Hispanic physicians are also well above the statewide average for
HPSA practice. Twenty-three percent of Hispanic physicians practice in metropolitan
HPSAs. Non-Hispanic white physicians, comprising almost three-quarters of the
physician workforce, have the lowest percentage of physicians practicing in HPSAs.
Figure 2.5
Percentage of New York State Physicians in HPSA and Non-HPSA Locations in 2000
by Race/Ethnicity*
100%
90%
80%
70%
69%
77%
60%
81%
82%
89%
85%
Non-HPSA
Metro HPSA
50%
Non-Metro HPSA
40%
30%
20%
31%
23%
10%
0%
18%
16%
<1%
1%
1%
2%
Black, NonHispanic
(n=1,512)
Hispanic
(n=1,338)
Asian
(n=5,658)
Other
(n=1,229)
10%
1%
White, NonHispanic
(n=24,080)
*None of the 14 NYS physicians identified as Native American/Alaskan Native practice in HPSAs
14
14%
1%
Missing
(n=14,150)
Estimated Initial Practice Years
The initial practice year for each physician was estimated by adding the year of medical
school graduation to the number of graduate medical education years required in each
physician’s specialty. Figure 2.6 illustrates the percentage of primary care physicians
practicing in New York State HPSAs in 2000 for cohorts of USMGs and IMGs estimated
to have completed training and initiated practice each year between 1980 and 1996.
IMGs initiating practice in the late 1980’s to the mid 1990’s have increasing percentages
of primary care practitioners in both metropolitan and non-metropolitan HPSAs, with a
drop among the most recent cohorts. USMGs have decreasing percentages of primary
care practitioners in non-metropolitan HPSAs among the same initial practice cohort, and
variable percentages in metropolitan HPSAs. There is an increase in these percentages
among the most recent USMG cohorts.
Figure 2.6.
Percentage of New York State USMG and IMG Primary Care
Physicians in HPSAs in New York State in 2000
by Estimated Initial Year of Practice
30%
25%
20%
IMG Metro
USMG Metro
15%
IMG Non-Metro
USMG Non-Metro
10%
5%
0%
80
81
82
83
84
85
86
87
88
89
15
90
91
92
93
94
95
96
New York State Medical Graduates
The physician data were analyzed by the medical school from which the physicians
graduated, and by graduates of medical schools in New York State specifically. There
are thirteen medical schools in New York (listed in Table 2.8). The physician data set
included physicians graduating from medical school after 1940. Four medical schools in
New York graduated their first classes after that year, as noted in the table. Therefore,
the pool of graduates in the data set for these schools is more limited than for schools that
graduated students in all years between 1941 and 1996. The medical schools also have
varying class sizes, which should be kept in mind in reviewing the tables in this section.
The total number of 1996 graduates for each medical school, the most recent year of
graduates included in the study, is presented in the last column of Table 2.8.
SUNY Downstate, the largest medical school in the state, has the largest number of all
physician graduates practicing in New York. SUNY Stony Brook, which is one of the
newest medical schools in the state, as well as one of the smallest, has the fewest
graduates practicing in New York. SUNY Upstate has the largest number of graduates
practicing in New York State HPSAs overall, the largest number in non-metropolitan
HPSAs, and the largest percentage of graduates practicing in HPSAs. New York Medical
College, the largest private medical school in the state, graduates the most New York
State physicians among the private medical schools. Columbia has the highest
percentage of graduates in New York State HPSAs among the private medical schools.
Table 2.8
Physicians Practicing in New York State in 2000 Who Are Graduates of
New York State Medical Schools
Total
Graduates in
Total
Graduates Percent of NYS NonTotal
Graduates in NYS Graduates Metropolitan Graduates
in NYS
HPSAs
in HPSAs
HPSAs
(1996)
Albany Medical College
Columbia College of Physicians and Surgeons
Albert Einstein College of Medicine*
Mt. Sinai School of Medicine*
New York College of Osteopathic Medicine*+
New York Medical College
New York University School of Medicine
SUNY at Buffalo School of Medicine and Biomedical Sciences
SUNY Downstate Medical Center College of Medicine
SUNY at Stony Brook Health Science Center*
SUNY Upstate Medical University
Joan and Stanford I Weill Medical College of Cornell University
University of Rochester School of Medicine and Dentistry
Total of New York State Medical Schools
1,016
1,204
1,545
909
686
1,956
1,863
1,516
2,791
589
1,502
842
709
73
236
160
99
54
171
149
249
283
53
354
79
81
7%
20%
10%
11%
8%
9%
8%
16%
10%
9%
24%
9%
11%
8
9
1
1
9
9
3
23
4
2
30
3
10
127
139
169
143
179
198
151
140
241
108
149
89
95
17,128
2,041
12%
112
1,928
*The Sophie Davis School of Biomedical Education at The City College of New York provides pre-clinical medical education only and does
does not grant medical degrees.
**These school graduated their first students after 1941 (AECOM 1959; MSSM 1970; NYCOM 1981; SUNY Stony Brook 1974)
+Data include only osteopathic graduates that completed allopathic residencies
16
Table 2.9
Primary Care Physicians Practicing in New York State in 2000
Who Are Graduates of New York State Medical Schools
Primary Care
Graduates
in NYS
Albany Medical College
Columbia College of Physicians and Surgeons
Albert Einstein College of Medicine*
Mt. Sinai School of Medicine*
New York College of Osteopathic Medicine*
New York Medical College
New York University School of Medicine
SUNY at Buffalo School of Medicine and Biomedical Science
SUNY Downstate Medical Center College of Medicine
SUNY at Stony Brook Health Science Center*
SUNY Upstate Medical University
Joan and Stanford I Weill Medical College of Cornell University
University of Rochester School of Medicine and Dentistry
Total of New York State Medical Schools
Primary Care
Graduates
Primary Care Percent of Primary in NYS NonGraduates in
Care Graduates
Metropolitan
NYS HPSAs
in NYS HPSAs
HPSAs
389
275
476
290
425
656
567
660
906
252
620
208
302
29
61
60
41
38
73
47
111
99
29
122
28
24
7%
22%
13%
14%
9%
11%
8%
17%
11%
12%
20%
13%
8%
4
5
0
0
6
6
2
15
1
1
19
0
4
6,026
762
13%
63
*Graduated first students after 1941 (AECOM 1959; MSSM 1970; NYCOM 1981; SUNY Stony Brook 1974)
Additional analysis found that SUNY Downstate has the most graduates practicing
primary care in New York State. SUNY Upstate has the largest number of primary care
physicians practicing in HPSAs overall and the largest number in non-metropolitan
HPSAs. New York Medical College graduates the most primary care physicians in New
York among the private medical schools. Columbia has the largest overall percentage of
primary care graduates practicing in New York State HPSAs.
Cross-tabulations were also conducted to identify the medical schools producing the most
graduates for New York State HPSAs. Table 2.10 presents the schools that have the
highest number of physician graduates practicing in New York’s non-metropolitan
HPSAs. Medical schools in New York State are the top six schools in the production of
non-metropolitan HPSA physicians for New York. Eight physicians each from schools
in Canada, Pakistan, and the Philippines practice in New York’s non-metropolitan
HPSAs.
A similar analysis was conducted to identify medical schools that have the highest
numbers of graduates practicing in New York’s metropolitan HPSAs. Again, six medical
schools in New York have the highest numbers of graduates in HPSAs. Several foreign
schools have high numbers, as does Howard University (See Table 2.11.)
17
Table 2.10
Medical Schools Graduating the Highest Number of New York State Physicians
Practicing in Non-Metropolitan HPSAs in 2000
Number of Physicians in NYS
Non-Metropolitan HPSAs
SUNY Upstate Medical University, Syracuse
SUNY at Buffalo School of Medicine and Biomedical Science
University of Rochester School of Medicine and Dentistry
Columbia College of Physicians and Surgeons
New York College of Osteopathic Medicine
New York University School of Medicine
Queens University, Fac of Med, Kingston, Ontario
McGill University, Fac of Med, Montreal, Quebec
King Edward Medical College, Univ. of Punjab, Pakistan
Dow Medical College, Univ. of Karachi, Pakistan
University of Santo Tomas, Fac of Med and Surg, Manila, Philippines
University of Pennsylvania School of Medicine
Georgetown University School of Medicine
30
23
10
9
9
9
8
8
8
8
8
7
7
Table 2.11
Medical Schools Graduating the Highest Number of New York State Physicians
Practicing in Metropolitan HPSAs in 2000
Number of Physicians in
NYS Metropolitan HPSAs
SUNY Upstate Medical University, Syracuse
SUNY Downstate Medical Center College of Medicine
Columbia College of Physicians and Surgeons
SUNY at Buffalo School of Medicine and Biomedical Science
New York Medical College
Albert Einstein College of Medicine
University of Santo Tomas, Fac of Med and Surg, Manila, Philippines
New York University School of Medicine
University D'Etat D'Haiti, Esc de Med et Pharmacie, Port-Au-Prince, Haiti
Mt. Sinai School of Medicine
Howard University
Univ. Auto de Guadalajara, Fac de Med, Guadalajara, Mexico
University of Rochester School of Medicine and Dentistry
18
324
279
227
226
162
159
154
146
108
98
82
82
71
Discussion
This study highlights the distribution of physicians in New York’s metropolitan and nonmetropolitan HPSAs. While data on the metropolitan and non-metropolitan distribution
of the 3.6 million New Yorkers residing in HPSAs were not available, total population
figures can provide some gauge. Thirty-eight percent of New York’s 62 counties are
designated as metropolitan counties, and 92 percent of New Yorkers reside in
metropolitan counties. Ninety-five percent of all physicians and 92 percent of primary
care physicians in HPSAs were found to practice in metropolitan counties.
The metropolitan and non-metropolitan distinctions are important because of the varied
distribution of New York’s population. The physicians practicing in metropolitan and
non-metropolitan HPSAs were found to differ in several ways. The more nonmetropolitan communities have a slightly higher proportion of primary care physicians in
the workforce and they are more likely to be family physicians. In metropolitan counties,
the primary care HPSA physicians are more likely to be internists.
The downstate metropolitan region in general has a higher proportion of physicians who
are female, international medical graduates, and minorities who are underrepresented in
medicine. In metropolitan regions, female primary care physicians are overrepresented in
HPSAs and in non-metropolitan regions they are underrepresented in HPSAs. This
study and others have found that female physicians are less likely to practice in rural
communities. The impact of this trend on the non-metropolitan physician workforce will
need to be monitored as the proportion of female physicians in the workforce continues to
grow.
Underrepresented minorities are far more likely to practice in HPSAs than white, nonHispanic physicians, but this difference is exclusively in metropolitan HPSAs. While
New York has a more diverse physician workforce than many states, it is still far from
representative of the population. The 2000 U.S. Census, which collects race and
ethnicity data separately, found that 68 percent of New York’s population is white, 16
percent is black, 5.5 percent is Asian, and 10 percent is “other” or reports two or more
races; fifteen percent of the population is of Hispanic or Latino origin (of any race).6
This compares to a physician workforce that is 71 percent non-Hispanic white, four
percent black, four percent Hispanic, 16 percent Asian, and four percent “other.” Less
than one percent of the population and the physician workforce is Native American/
Alaskan Native.
Efforts to increase the number of physicians who are underrepresented minorities, such as
the 3000 by 2000 initiative of the Association of American Medical Colleges, have not
been successful. Intensified efforts to increase the proportion of minorities in medicine
are overdue, given the State’s shifting demographics, increasing evidence of disparities in
health care based on race and ethnicity, minority physicians’ tendency to practice in
19
shortage areas and in minority communities at higher rates, and longstanding minority
under representation in the physician workforce.
While IMGs make up a larger proportion of the physician workforce in the downstate
metropolitan region, they practice in HPSAs at higher rates than USMGs in all regions of
the state. Foreign medical schools are some of the largest producers of New York’s
HPSA physicians in both metropolitan and non-metropolitan communities. The number
of three-year limited medical licenses issued to foreign citizens which require practice in
a physician shortage area has increased from 188 in 1998 to 294 in 2002.7 Reliance on
IMGs to fill gaps in the U.S. physician workforce has been the subject of much debate
and has been questioned on ethical grounds.
Medical schools in New York State graduated 36 percent of the physicians practicing in
New York in 2000 and 30 percent of those practicing in HPSAs. Thirty-three percent of
those practicing primary care graduated from medical schools in New York, as did 27
percent of those practicing primary care in HPSAs. The location of residency training
has been shown to have a strong correlation to eventual practice location. Further review
of paths toward practice in a HPSA should include residency data.
The characteristics of physicians most likely to practice in HPSAs can be identified and
used to target recruitment for underserved communities. While ensuring an ample supply
of physicians in New York’s varied communities is an important step and a complicated
undertaking, the issue of access to care goes beyond the presence of physicians. Nearly
one third of New York’s HPSAs are special population designations, meaning that
barriers to care beyond physician supply limit the health care available to the community.
Both supply and access issues need to be addressed.
20
Nurse Practitioners in New York State
Background
The 2000 National Sample Survey of Registered Nurses reports that there are an
estimated 88,186 nurse practitioners in the U.S., and another 14,643 nurse practitioners
who are jointly prepared as clinical nurse specialists.8 Another nurse practitioner survey
conducted in New York State in March of 2000 found 6,120 nurse practitioners active as
NPs in the state, 5,215 of which were in the primary care specialties examined in this
report.7
The number of nurse practitioners (NPs) has grown rapidly over the past decade, both
nationally and in New York State. The number of registered nurses certified as NPs in
New York State increased by 340 percent in the eight years between 1993 and 2001.
New York has the second highest number of total nurse practitioners certificates held (as
of 1999) with 8,948, second only to California which has 10,126.9
Nurse practitioners in New York State are required to practice and prescribe using
protocols developed in collaboration with a physician. These regulations are somewhat
more restrictive than half the states, which have no requirements for physician
collaboration or supervision. A number of states have tighter restrictions that require
physician supervision.9 In this report, the distribution of primary care nurse practitioners
in New York State is examined by AHEC regions and by health professional shortage
areas.
Study Methods
Data were obtained from a national survey of nurse practitioners conducted by the
American Academy of Nurse Practitioners (AANP). The AANP conducted the survey in
1999 using addresses obtained from the 50 state boards of nursing and the District of
Columbia. Surveys were sent to 59,392 nurse practitioners. Responses were received
from 28,856 nurse practitioners, yielding a 49 percent response rate. It is unknown
whether a response bias exists, as data on all survey recipients were not made available.
Of these respondents, 23,563 records were complete and met the definition of primary
care used in this report, which includes nurse practitioners specializing in the areas of
adult, family, family planning, geriatric, pediatric, school, and women’s health practice.
Data identifying year of graduation from nurse practitioner education programs were not
available and the corresponding analyses could not be conducted.
Nurse practitioners in New York State were identified by the state code in each record
and NPs in specific AHEC regions were identified by county codes. A total of 2,732
New York State primary care nurse practitioners were included in this data set.
21
Variables used in the analysis include work address and practice specialty. Data on other
characteristics of nurse practitioners were not available, although subsequent AANP
surveys are seeking additional data. The nurse practitioner data were cross-referenced
with the 1999 primary care HPSA file to locate nurse practitioners’ practice addresses
within HPSA census tracts. Geographic HPSAs and low-income special population
HPSAs were used in this analysis. HPSA census tracts were classified as either
metropolitan or non-metropolitan.
Nurse practitioners whose practice addresses were located in a census tract within a
HPSA boundary, identified as either metropolitan or non-metropolitan, were coded
correspondingly. Cross-tabulations were conducted for the available variables and are
presented in the findings below.
Findings
New York Compared to Other States
New York was found to have the largest number of nurse practitioners of any state. It
also has the largest number of NPs in HPSAs, despite having one of the lowest number of
total HPSA designations and a lower HPSA population than other large states. New
York has the highest number of institutions offering at least one nurse practitioner
education program and most of these offer several programs.
Table 3.1
Primary Care Nurse Practitioners in Practice in the U.S. and Selected States in 1999
Total Nurse Practitioners*
U.S.
23,563
NY
2,732
Nurse Practitioners in HPSAs
4,326
701
401
157
44
292
% NPs in HPSAs
18%
26%
15%
12%
18%
22%
# of HPSA Designations**
2,968
102
Estimated HPSA population**
51,551,841 3,599,085
# Institutions offering at least one
NA
25
primary care NP Program***
Number of 1999 NP licenses held+
81,103
8,948
Total Population (in millions as of
7/1/01)
285.3
19.1
CA
2,619
FL
1,259
IL
249
TX
1,355
170
113
101
241
3,633,367
21
2,319,040
12
1,494,582
9
5,250,396
21
10,126
5,525
1,000
3,666
34.6
16.4
12.5
21.8
*Based on 49% response to AANP survey
**As of 6/30/01 ***From American Academy of Nurse Practitioners NP Program Listing
+From Annual Legislative Update, The Nurse Practitioner, January 2001 (may include duplicate and multiple licenses)
Nurse Practitioners in New York
Family nurse practitioners (FNPs) make up the largest number of NPs in the state and
represent 38 percent of the New York State NPs in this study (see Table 3.2). FNPs
outnumber adult nurse practitioners, the next largest specialty, in all AHEC regions
except the most urban. Only in the Brooklyn-Queens-Long Island and Manhattan-Staten
Island AHECs do adult nurse practitioners outnumber family nurse practitioners.
22
Table 3.2
Primary Care Nurse Practitioners in New York State AHEC Regions in 1999*
AHEC
New York State
Bronx-Westchester
Brooklyn-Queens-Long Island
Catskill-Hudson
Central New York
Erie/Niagara
Hudson-Mohawk
Manhattan/Staten Island
Northern
Western New York
County data missing
Total
Family GerontoWomen’s Specialty
NPs Adult Family Planning logical Pediatric School Health
Missing
2732
247
531
159
505
270
154
378
83
388
17
735
48
192
16
126
73
24
139
22
87
8
1025
111
110
101
248
75
84
100
41
149
6
5
1
0
1
0
0
2
0
0
1
0
119
11
29
1
21
10
2
23
1
21
0
437
45
95
16
56
54
21
67
1
81
1
21
3
1
3
2
3
0
3
1
5
0
386
28
104
20
52
53
21
45
17
44
2
4
0
0
1
0
2
0
1
0
0
0
*Based on 49% response to national AANP survey
While 26 percent of all primary care nurse practitioners in New York State are located in
HPSAs, this rate varies between 3 percent and 71 percent among the AHEC regions (see
Table 3.3). Of the 700 primary care nurse practitioners found to practice in HPSAs, 70
percent of them are located in metropolitan HPSAs. Family nurse practitioners account
for over 60 percent of all NPs in non-metropolitan HPSAs. In only two AHEC regions
are there more primary care nurse practitioners in non-metropolitan locations than
metropolitan (Catskill-Hudson and Northern). The highest percentages of nurse
practitioners in HPSAs are in the more rural AHECs, specifically the Northern and
Central New York AHECs.
Table 3.3
Primary Care Nurse Practitioners in New York State HPSAs in 1999*
Total NPs
AHEC
New York State
Bronx-Westchester
Brooklyn-Queens-Long Island
Catskill-Hudson
Central New York
Erie/Niagara
Hudson-Mohawk
Manhattan/Staten Island
Northern
Western New York
2732
247
531
159
505
270
154
378
83
388
NPs in
HPSAs
700
31
69
36
258
8
11
145
59
83
% in HPSAs
26%
13%
13%
23%
51%
3%
7%
38%
71%
21%
Metro
HPSAs
491
31
69
6
175
7
8
145
0
50
Non-Metro
HPSAs
209
0
0
30
83
1
3
0
59
33
*Based on 49% response rate
Consistent with findings from the national data set, family nurse practitioners are overrepresented in HPSAs in New York State compared to their proportion in the overall
nurse practitioners workforce. Family nurse practitioners make up 38 percent of the
statewide workforce and 42 percent of the nurse practitioners in HPSAs. Other
specialties are slightly underrepresented in HPSAs compared to their representation in the
New York workforce (see Table 3.4).
23
Table 3.4
Primary Care Nurse Practitioners in New York State Metropolitan
and Non-metropolitan HPSAs in 1999 by Specialty*
Adult
AHEC
New York State
Bronx-Westchester
Brooklyn-Queens-Long Island
Catskill-Hudson
Central New York
Erie/Niagara
Hudson-Mohawk
Manhattan/Staten Island
Northern
Western New York Rural
Family
Family
Geronto- Pediatric School Women's
Planning
logical
Health
Met Non Met Non Met Non Met Non- Met Non Met Non Met Non
-Met
-Met
-Met
Met
-Met
-Met
-Met
139 39 164 128 0
1
23
2
91 15
3
1
71 23
5
10
8
8
14
19
8
13
15
3
5
23
1
2
1
1
63 14 61 52
3
2
28
8
1
19
7
2
3
1
1
1
1
4
3
3
45
42
10
30
2
16
18
29
1
11
9
4
20 20
2
11
5
8
4
*Based on a 49% response rate
Discussion
Nurse practitioners practice in HPSAs at higher rates than other primary care health
professionals. Family nurse practitioner have the highest rate of HPSA practice overall,
and practice in non-metropolitan HPSAs in much higher numbers than nurse practitioners
in other specialties.
With graduations from baccalaureate nursing programs stabilizing and showing some
projected increases,10 the number of nurse practitioner graduates also might continue to
increase. Given their high rates of practice in HPSAs, nurse practitioners are in a
position to make continued contributions to the primary care workforce in shortage areas.
Practice data linked to nurse practitioners’ initial certification data and/or length of time
at a particular practice location will permit analyses of trends in workforce distribution.
24
Certified Nurse Midwives in New York State
Background
The 2000 National Sample Survey of Registered Nurses reports that an estimated 9,232
registered nurses are prepared for advanced practice as nurse midwives.8 An annual
survey of state boards of nursing and other organizations reported a total of 8,398
certified nurse midwives (CNMs) nationally, and 856 in New York State.9 Because the
survey does not account for duplicate licenses in more than one state or employment
status, the number of practicing CNMs is assumed to be lower. The New York State
Board of Education’s Office of the Professions listed 895 certified nurse midwives
maintaining licensure in New York State in 2001, the year studied in this report. This
number rose to 960 as of April 1, 2004.11
The American College of Nurse Midwives reports that there are 402 nurse-midwifery
practice sites throughout New York State and that, in 2002, certified nurse
midwives/certified midwives attended nearly 28,000 births or approximately 11 percent
of all births.12 New York is one of 16 states in which “direct entry” into midwifery from
non-nursing health professions is legal and regulated.
In this report, the distribution of certified nurse midwives in New York State is examined
by AHEC regions and by health professional shortage areas.
Study Methods
Data files from the American College of Nurse Midwives (ACNM) were used to identify
certified nurse midwives. The ACNM data are compiled from annual member and
midwifery practice site questionnaires. As of July 2001, the national ACNM member
database contained records for 7,646 certified nurse midwives, of which 5,220 records
had complete U.S. practice address information and could be used for HPSA analysis. A
total of 555 CNMs were found to have practice addresses in New York State; these
certified nurse midwives are included in the following analysis. Other variables in the
ACNM data file that were relevant to this study include year of initial nurse midwifery
certification and race/ethnicity.
A primary medical HPSA data file, current as of July 2001, was used to identify health
profession shortage areas. Certified nurse midwives practicing in HPSA locations were
identified by cross-referencing the ACNM file with the HPSA file. The resulting crosstabulations of the CNM variables are described in the following section.
25
Findings
New York Compared to Other States
New York State was found to have the largest number of certified nurse midwives in the
ACNM data set (see Table 4.1). New York also has the highest number and percentage
of CNMs in HPSAs, despite having a smaller HPSA population than several other states.
Table 4.1
Certified Nurse Midwives in Practice in the U.S. and Selected States in 2001
U.S.
Total Certified Nurse Midwives
5,220
Certified Nurse Midwives in HPSAs
828
% CNMs in HPSAs
16%
# of HPSA Designations*
2,968
Estimated HPSA population*
51,551,841
# of CNM Education Programs**
45
Total Population (in millions as of
285.3
7/1/01)***
NY
555
149
27%
102
3,599,085
4
19.1
CA
481
81
17%
170
3,633,367
3
34.6
FL
330
19
6%
113
2,319,040
2
16.4
IL
211
12
6%
101
1,494,582
1
12.5
TX
208
40
19%
241
5,250,396
4
21.4
*As of 6/30/01 Source: HRSA, BHPr, Division of Shortage Designation
**ACNM-accredited programs as of 2/26/04
***Source: U.S. Census Bureau
Certified Nurse Midwives in New York
Over sixty percent of New York State’s certified nurse midwives practice in the
metropolitan region (see Table 4.2). The Brooklyn-Queens-Long Island AHEC, with the
largest population, has the highest number of CNMs. The Northern AHEC, comprised of
all non-metropolitan counties, has the smallest population and the lowest number of
CNMs but the highest proportion of them in HPSAs.
Table 4.2
Certified Nurse Midwives in New York State AHEC Regions in 2001
CNMC
New York State
Bronx-Westchester AHEC
Brooklyn-Queens-Long Island AHEC
Catskill-Hudson AHEC
Central New York AHEC
Erie/Niagara AHEC
Hudson-Mohawk AHEC
Manhattan/Staten Island AHEC
Northern AHEC
Western New York Rural AHEC
Total
CNMs
CNMs in
HPSAs
Percent
in HPSAs
CNMs in
Metro
HPSAs
CNMs in
Non-Metro
HPSAs
555
99
145
57
57
18
43
96
15
25
149
26
35
6
20
1
3
39
9
10
27%
26%
24%
11%
35%
6%
7%
41%
60%
40%
121
26
35
3
8
1
1
39
*
8
28
*
*
3
12
*
2
*
9
2
*No HPSAs of this type in the AHEC region
26
Statewide, over eighty percent of the CNMs in HPSAs practice in metropolitan HPSAs.
Figure 4.1 presents the distribution of CNMs in each AHEC region by HPSA and nonHPSA practice locations.
Figure 4.1
CNMs by AHEC Region and 2001 HPSA/Non-HPSA Work Location
Bronx-Westchester AHEC
26
Brooklyn-Queens-Long
Island AHEC
73
35
110
Catskill-Hudson AHEC 3 3
Central New York AHEC
51
8
12
37
CNMs in Metro HPSAs
Erie/Niagara AHEC 1
17
CNMs in Non-Metro HPSAs
CNMs in Non-HPSAs
Hudson-Mohawk AHEC 12
40
Manhattan/Staten Island
AHEC
39
Northern AHEC
9
Western New York Rural
AHEC
8 2
0
57
6
15
20
40
60
80
100
120
140
160
Data on race and ethnicity were available for 89 percent of the CNMs in New York State.
The racial and ethnic classifications used by the ACNM are reported in these findings.
The CNM population in New York State, and the nation, is overwhelmingly white.
Eighty-six percent of New York’s CNMs for whom race or ethnicity is known are white,
nine percent are black, three percent are Hispanic, and two percent are Asian. This
distribution is more diverse than findings for the nation as a whole. Nationally, 92
percent of CNMs for whom race and ethnicity is known are white, four percent are black,
two percent are Hispanic and less than one percent is Asian. Eighteen CNMs identified
themselves as Indian, none of whom practice in New York State.
CNMs who identified their race or ethnicity as black, Hispanic, or Asian are clustered in
the New York City metropolitan region. All Asian CNMs, and all but two of the black
and Hispanic CNMs are located in either the Bronx-Westchester, Brooklyn-Queens-Long
Island, or Manhattan-Staten Island AHECs. The number of CNMs in HPSAs is not
presented by racial and ethnic classifications due to the small numbers in these
classifications.
27
Table 4.3
Certified Nurse Midwives in New York State AHECs by Race/Ethnicity (2001)
New York State
Bronx-Westchester AHEC
Brooklyn-Queens-Long Island AHEC
Catskill-Hudson AHEC
Central New York AHEC
Erie/Niagara AHEC
Hudson-Mohawk AHEC
Manhattan/Staten Island AHEC
Northern AHEC
Western New York Rural AHEC
Asian
10
1
6
Black
43
7
24
1
Hispanic
16
7
4
1
3
10
1
3
1
White
421
71
86
52
49
18
40
71
14
20
Race
Unknown
63
13
23
3
8
Other
2
2
2
9
1
4
Figure 4.2 and Table 4.4 report on CNMs by year of certification. There is no clear
pattern in the overall number of CNMs practicing in 2001 based on their year of
midwifery certification. Their distribution in metropolitan and non-metropolitan HPSAs
does not appear to be related to the number certified in any given year.
Figure 4.2
Number of 2001 NYS CNMs in Metropolitan HPSAs, Non-Metropolitan HPSAs
and Non-HPSA Practice Locations by Year of Certification
50
45
40
35
30
Non-HPSA
25
36
HPSA Non-Metro
HPSA Metro
23
20
11
22
20
20
15
20
23
11
14
21
10
2
1
1
5
8
6
1
2
1990
1991
0
15
1
5
1993
1994
3
8
3
2
1992
2
3
6
4
1995
28
1996
1997
1998
8
4
1999
2000
Table 4.4
Number of CNMs in NYS AHEC Regions in 2001 by Year of Certification (1990-2000)
AHEC
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
Bronx-Westchester
4
2
4
3
3
6
6
2
6
2
3
Brooklyn-Queens-Long Island
10
5
7
7
6
14
14
7
8
7
4
Catskill-Hudson
6
2
3
3
4
3
3
2
1
1
1
Central New York
1
3
3
3
5
4
4
4
4
6
2
Erie/Niagara
0
3
1
1
0
2
2
0
1
1
0
Hudson-Mohawk
1
4
2
1
2
3
3
4
5
2
1
Manhattan/Staten Island
4
5
9
6
6
6
6
6
2
2
6
Northern
1
0
0
0
2
4
4
0
0
0
4
Western New York Rural
0
0
3
2
0
1
1
3
0
0
0
Discussion
Certified nurse midwives in New York State practice in HPSAs at a rate similar to that of
nurse practitioners, and at twice the rate of obstetrician-gynecologists. New York State
CNMs practice in HPSAs at higher rates than their colleagues in other states. Despite
the fact that all of New York’s nurse midwifery education programs are located
downstate, almost twenty percent of CNMs practice in non-metropolitan HPSAs. Even
with relatively small numbers of practitioners, CNMs have a strong presence in HPSAs.
The CNM workforce in New York is more racially and ethnically diverse than in other
states, although it is not representative of the state’s population. Further,
underrepresented minority CNMs are clustered in the New York metropolitan region with
little diversity in the rest of the state. As with other advanced nursing professions, more
must be done to recruit minority nurses into the CNM workforce.
29
Certified Registered Nurse Anesthetists in New York State
Background
The 2000 National Sample Survey of Registered Nurses (NSSRN) estimated that there
are 29,844 nurse anesthetists in the U.S., which represents a slight decrease of about 500
from the estimate of the nurse anesthetist workforce in the previous NSSRN survey
conducted in 1996. Certified registered nurse anesthetists (CRNAs) were the only
advanced practice nurses in the survey to experience a decrease rather than an increase in
that four-year interval. A survey of state nursing authorities reported 32,640 certified
registered nurse anesthetists nationally in 2000, a number which may contain duplicate
reporting across states as well as professionally inactive CRNAs.9
New York State does not maintain a census of CRNAs. Current membership data from
the American Association of Nurse Anesthetists counts 693 active members from New
York, although this represents CRNAs with work or home addresses in the state.13 A
1998 study of New York State CRNAs placed the total number of CRNAs at 627 using a
zip code of residence.14
Study Methods
Data on nurse anesthetists were obtained from a national survey conducted in late 2000
by the American Association of Nurse Anesthetists. The data yielded responses from
15,165 nurse anesthetists to produce a sixty percent response rate. Respondents were
asked to provide the zip code of their primary practice setting and 12,181 of the
responding CRNAs did so. Absent a complete work address, zip codes were used to
identify practitioners in HPSAs. The center point of each zip code was geocoded and
cross-referenced with the corresponding the census tract. Zip codes in the range between
10000 and 14999 were used to identify 334 CRNAs with work locations in New York
State. Zip code ranges for the other states included in the cross-state comparisons were
used accordingly.
These data were cross-referenced with the 2001 primary care HPSA file to identify nurse
anesthetists whose primary practice zip codes were located within HPSA boundaries.
Additional variables included in the analysis were gender, age, and number of years in
practice (in ranges). The findings are described below.
Findings
New York Compared to Other States
New York was found to have the smallest number of certified registered nurse
anesthetists among the five most populous states, and New York-based CRNAs
comprised fewer than three percent of those in the national AANA data set (see Table
5.1). In contrast, New York State was found to have the largest nurse practitioner and
30
certified nurse midwifery workforces among these states as described in other sections of
this report. Consistent with the other advanced practice nursing professions, however,
New York State was found to have the highest proportion of CRNAs in HPSAs at 19.8
percent.
New York has the second highest number of physician anesthesiologists, after California,
which points to an anesthesia-provider mix that is more physician dominated than in
other largely populated states, such as Florida and Texas.
Table 5.1
Certified Registered Nurse Anesthetists in Practice in the U.S. and Selected States in 2001
U.S.
NY
CA
FL
IL
TX
Total CRNAs*
CRNAs in HPSAs
% CRNAs in HPSAs
# of HPSA Designations**
Estimated underserved population
12,182
1,285
10.5%
2,968
29,589,057
334
66
19.8%
102
1,762,156
398
43
10.8%
170
2,038,937
738
33
4.8%
113
1,450,059
356
25
7.0%
101
923,132
832
74
8.9%
241
2,715,442
# of CRNA Education Programs***
# of Physician Anesthesiologists+
90
33,826
4
2,987
3
4,154
5
2,053
4
1,591
4
2,476
Physician anesthesiologist/CRNA ratio
2.8:1
8.9:1
10.4:1
2.8:1
4.5:1
3.0:1
Total Population (in millions as of
7/1/01)
285.3
19.1
34.6
16.4
12.5
21.4
*Based on a 60% response to AANA survey **As of 6/30/01
***As listed in the AANA web site (AANA.com)
+Non-federal patient care physicians as reported in AMA’s Physician Characteristics and Distribution in the
U.S.: 2002-2003 Edition
CRNAs in New York
Out of the 334 New York State CRNAs responding to the AANA survey and providing a
work zip code, 66 were found to practice in HPSAs. The proportion of CRNAs
practicing in New York’s AHEC regions varies, as does the proportion practicing in
HPSAs. The Brooklyn-Queens-Long Island AHEC has the largest number of CRNAs
with 73, while the Bronx-Westchester AHEC has the lowest number with nine. In two
AHECs—Hudson-Mohawk and Bronx-Westchester—none of the CRNAs practiced in
HPSAs. The Central New York AHEC had the largest number of CRNAs in HPSAs at
29, comprising 58 percent of all CRNAs in that AHEC region.
Of the 66 survey respondents who had a work zip code located in a HPSA, 40 of them
were found to practice in metropolitan HPSAs. Four AHEC regions had CRNAs located
in metropolitan HPSAs and five had CRNAs located in non-metropolitan HPSAs. Two
AHEC regions had CRNAs located in both.
31
Figure 5.1
CRNAs in New York State AHEC Regions
by 2001 HPSA/Non-HPSA Practice Location
Bronx-Westchester AHEC
9
Brooklyn-Queens-Long
Island AHEC
4
69
Catskill-Hudson AHEC 2
20
Central New York AHEC
24
5
21
Metro HPSA
Erie/Niagara AHEC 2
46
Non-Metro HPSA
Non-HPSA
39
Hudson-Mohawk AHEC
Manhattan/Staten Island
AHEC
11
43
14
Northern AHEC
3
Western New York Rural
1 3
AHEC
0
18
10
20
30
40
50
60
70
80
The distribution of CRNAs was analyzed by age and is presented in Table 5.2. The
largest proportion of CRNAs (44%) was found in the 40-49-age range. This was found to
be the age range with the largest distribution of CRNAs in almost all of the AHEC
regions, although the percentage varied. The Brooklyn-Queens-Long Island AHEC had
the largest proportion of CRNAs over age 60. Only three New York CRNAs (less than
one percent) were under 30 years of age, while nationally nearly two percent, or 173,
were in this age category. The age distribution of CRNAs in New York State did not
vary markedly from that in the nation as a whole.
Table 5.2
CRNAs in New York State AHEC Regions in 2001 by Age
AHEC
New York State
Bronx-Westchester
Brooklyn-Queens-Long Island
Catskill-Hudson
Central New York
Erie/Niagara
Hudson-Mohawk
Manhattan/Staten Island
Northern
Western New York Rural
Total
CRNAs
334
9
73
22
50
48
39
54
17
22
Under
30
3
1
0
0
1
0
0
1
0
0
30-39
40-49
50-59
60+
66
4
14
6
13
8
4
9
3
5
148
1
30
7
21
27
21
21
7
13
92
3
18
7
14
11
12
17
6
4
24
0
11
2
1
2
2
5
1
0
32
Missing
age
1
1
CRNAs practicing in HPSAs were also analyzed by age for New York State and the U.S.
Sixty-one percent of New York’s CRNAs in HPSAs were located in metropolitan
HPSAs, while in the nation as a whole 58 percent were in metropolitan HPSAs. In New
York, the proportion of HPSA CRNAs in non-metropolitan HPSAs was slightly higher in
each successive age bracket. This difference in HPSA distribution among age groups
was much more pronounced in the national CRNA data, with substantial decreases in the
percentage of non-metropolitan CRNAs for each younger age bracket. Among those
under age 30, only 15 percent were found in non-metropolitan HPSAs nationally. New
York State has a higher metropolitan distribution of HPSA CRNAs for all age brackets.
Table 5.3
CRNAs in Metropolitan and Non-Metropolitan New York State HPSAs by Age
Age
Under 30 30-39
40-49
50-59
60+
missing
Total
Metro HPSA
1
7
20
12
0
0
40
Non-Metro HPSA
0
4
12
8
2
0
26
Non-HPSA
2
55
116
72
22
1
268
CRNAs were further analyzed by gender and HPSA distribution (see Figures 5.2 and
5.3). Male CRNAs were more likely than female CRNAs to practice in HPSAs both in
New York State and in the nation as a whole. In New York, 25 percent of male CRNAs
were found to practice in HPSAs, while 16 percent of females were in HPSAs. Among
survey respondents nationally, 12 percent of male and 10 percent of female CRNAs were
found to practice in HPSAs.
Male CRNAs were found to be more heavily distributed in non-metropolitan HPSAs,
while female CRNAs were more heavily distributed in metropolitan HPSA. This finding
was similar for the nation as a whole, and has been corroborated by other studies.15, 16
In New York, the HPSA distributions of male and female CRNAs were nearly mirror
images of each other; 25 male CRNAs were found in non-metropolitan HPSAs and 7 in
metropolitan HPSAs, while 26 female CRNAs were found in metropolitan HPSAs and 6
in non-metropolitan HPSAs.
33
Figure 5.2.
Male CRNAs by AHEC Region and 2001 HPSA/Non-HPSA Practice Location
3
Bronx-Westchester AHEC
Brooklyn-Queens-Long
Island AHEC
24
Catskill-Hudson AHEC 1
10
Central New York AHEC
11
3
11
Non-Metro HPSA
Erie/Niagara AHEC
2
Metro HPSA
18
Non-HPSA
Hudson-Mohawk AHEC
11
Manhattan/Staten Island
AHEC
2
10
10
Northern AHEC
3
Western New York Rural
1 2
AHEC
8
0
5
10
15
20
25
30
35
40
45
50
Figure 5.3
Female CRNAs by AHEC Region and 2001 HPSA and Non-HPSA Practice Location
Bronx-Westchester AHEC
6
Brooklyn-Queens-Long
Island AHEC
3
40
Catskill-Hudson AHEC 1
Central New York AHEC
10
2
13
10
Non-Metro HPSA
Erie/Niagara AHEC
27
Metro HPSA
Non-HPSA
Hudson-Mohawk AHEC
28
Manhattan/Staten Island
AHEC
9
Northern AHEC
31
3
Western New York Rural
1
AHEC
0
10
5
10
15
20
25
34
30
35
40
45
50
In an analysis of CRNAs in New York by the number of years in practice, over twothirds of the CRNAs were found to have been in practice for 11 or more years. Among
those practicing in non-metropolitan HPSAs, 84 percent have been in practice for 11 or
more years (See Table 4). Fifty-nine percent of those practicing in metropolitan HPSAs
have been in practice for 11 or more years. While the data do not provide the number of
years a CRNA has been in a particular practice location, those in non-metropolitan
HPSAs in 2001 had more years in practice overall than those in non-HPSA locations
while those in metropolitan HPSAs in 2001 tended to have fewer years in practice than
those in non-HPSA locations.
Table 5.4
CRNAs in New York State by Number of Years in Practice (2001)
Less than
2 years
2–5
years
6 – 10
years
11 - 20
years
More
than
20 years
Missing
New York State
15
42
48
116
109
4
Bronx-Westchester AHEC
2
2
1
Brooklyn-Queens-Long Island AHEC
2
7
12
28
21
2
5
7
8
Catskill-Hudson AHEC
4
Central New York AHEC
5
8
5
16
16
Erie-Niagara AHEC
3
4
11
18
12
Hudson-Mohawk AHEC
3
4
3
16
13
Manhattan-Staten Island AHEC
9
6
15
24
Northern AHEC
2
2
6
6
Western New York Rural AHEC
4
3
10
5
3
1
Table 5.5
New York State CRNAs in HPSA Locations by Years in Practice (2001)
Years in Practice
Metro HPSA
Non-metro HPSA
Non-HPSA
Less than 2 years
5
0
10
2 – 5 years
6
3
33
6 - 10 years
5
1
42
11 - 20 years
12
10
94
More than 20 years
11
11
87
*4 CRNAs in HPSAs have missing values for years in practice
Discussion
The data provided here present a snapshot of the CRNA workforce in New York State.
The findings indicate that the New York anesthesia workforce relies less on CRNAs and
more on physician anesthesiologists than other large states. The two largest AHEC
regions, Brooklyn-Queens-Long Island and Bronx-Westchester, have a markedly smaller
distribution of CRNAs per population than the state as a whole.
35
New York has a larger proportion of CRNAs practicing in HPSAs than other large states
and the nation as a whole. CRNAs in New York State HPSAs are more heavily
distributed in metropolitan HPSAs than they are nationally. While CRNAs in New
York’s non-metropolitan HPSAs tend to be older and have more years of practice, this
finding was not as marked as for the nation as a whole. For example, of CRNAs
nationally who are ages 50-59 and practice in a HPSA, 52 percent of them are in nonmetropolitan HPSAs; in New York only 40 percent of HPSA CRNAs in this age range
practice in non-metropolitan HPSAs.
Gender clearly plays a role in HPSA distribution of CRNAs both in New York and the
nation. Male CRNAs are more likely to practice in HPSAs than female CRNAs, and
when they practice in HPSAs they are more likely to choose non-metropolitan HPSA
locations. This suggests that targeting male CRNAs may be a successful recruitment
strategy for non-metropolitan HPSAs.
New York does not independently collect data on certified registered nurse anesthetists
through registration or certification, as it does for nurse practitioners and nurse
midwives/midwives. AANA data are a useful alternative, although follow-up surveys
with higher response rates, combined with encouragement from New York’s state CRNA
leadership, would provide more complete data in the future.
36
Recent Dental Graduates in New York State
Background
New York State has 36 federally designated dental health professional shortage areas
(DHPSAs) in which 1.7 million New Yorkers reside, and one million of these residents
are estimated to be underserved.17 Thirteen of these designations identify geographic
areas where the ratio of people to dentists exceeds 5,000 to one. One designation is for a
facility and the remaining 22 designations identify communities where the population
experiences barriers to dental care.
Common barriers to care include lack of insurance, inability to pay, or lack of dentists
willing to accept Medicaid-insured individuals. According to the National Oral Health
Surveillance System, 18 percent of New York dentists are enrolled in Medicaid and only
5 percent are enrolled in the State Child Health Insurance Plan.18 Data are not available
for all states, but in other large states to which New York is compared (see Findings)
enrollment rates are slightly higher. Texas has a Medicaid enrollment rate of 20 percent
and Illinois has a rate of 24 percent.
Communities that are designated as DHPSAs are eligible to be placement sites for
dentists serving in the National Health Service Corps (NHSC). In 2002, 12 NHSC
dentists were fulfilling service obligations in New York State.19 A total of 17,366
individuals hold New York State licenses to practice dentistry and 14,932 registered
dentists identify a main office address in New York State.20
The following sections report on the distribution of recently graduated dentists in New
York State among the nine regions comprising New York State’s Area Health Education
Center System, as well as their distribution in DHPSAs. These data reflect the practice
decisions of the newest entrants to the dental workforce and may provide signs of future
trends. New York’s population of new dentists is also compared to those of other large
states.
Study Methods
The American Dental Association (ADA) provided data, current as of December 2001,
on all dentists who had graduated from dental school between 1993 and 2001. Variables
included specialty, primary occupation, gender, hours worked (over 30 hours per week or
fewer than 30 hours per week), and the census tract in which the practice was located.
Dentists graduating in 2000 and 2001 are not included in the analysis as a portion of these
graduates would have been completing a dental residency in 2001 and the data on
practicing dentists for those graduation years would be incomplete. Data on dentists
graduating prior to 1993 were not made available by the ADA. Consequently, data for
recently graduated dentists could not be compared with the entire ADA data set. These
data represent new entrants into the dental workforce between 1993 and 1999.
37
Dentists in New York State were identified by the state code in each record and dentists
in specific AHEC regions were identified by county codes. A total of 2,905 New York
State dentists were included in this data set, which represents approximately 19.5 percent
of registered dentists in the state.
The dental data were cross-referenced with a 2001 dental health professional shortage
area (DHPSA) file using SAS and MapInfo software. Dentists whose practice addresses
were located in a census tract within a DHPSA boundary, identified as either
metropolitan or non-metropolitan, were coded correspondingly. Cross-tabulations were
conducted for the available variables and are presented in the findings below.
Findings
New York Compared to Other States
In a comparison of dentist data for the five most populous states (see Table 6.1), only
California and New York had a greater percentage of dentists from the recent dental
school graduation cohort than their respective percentages of the U.S. population. New
York State has the second highest number of dental schools of any state with four, behind
California which has five. It is also home to the New York University College of
Dentistry which is the largest dental school in the country and has a total enrollment
twice that of the next largest dental school.
New York State has fewer total DHPSA designations than other comparable states.
Despite this, New York State has one of the highest DHPSA populations with over 1.7
million residents living in communities so designated. A review of state-by-state
DHPSA data identifies total designations, underserved populations, and dentists in
DHPSAs that are not correlated to total state population and may reflect varying levels of
effort by states and communities to gain DHPSA designations. A critique of the DHPSA
designation process and criteria was recently published by the UCSF Center for
California Health Workforce Studies.21
The state-by-state variation in DHPSA designations clearly plays a role in the analysis of
dentists in DHPSAs by state. In New York State, seven percent of recent dental
graduates were found to practice in DHPSAs. These rates varied between one percent
and 46 percent among the five largest states in the country, reflecting an inconsistency in
analysis of the dental workforce using DHPSAs that was not found in an analysis of
dentists in primary care HPSAs.
38
Table 6.1
Recent Dental Graduates (1993 – 1999) in Practice in the U.S. and Selected States in 2001
Total Dentists (1993-99 Graduates)
Dentists in Dental HPSAs
% in Dental HPSAs
# of DHPSA Designations*
DHPSA population*
# of Dental Schools
Dentists in Primary Care HPSAs
% in Primary Care HPSAs
# of PCHPSA Designations*
Total Population (in millions as of 7/1/01)
U.S.
27,272
3,920
14%
1,695
34,292,315
55
1,683
NY
2,905
209
7%
36
1,745,581
4
270
CA
4,098
45
1%
52
848,247
5
154
FL
1,167
75
6%
95
1,373,920
2
22
IL
1,143
527
46%
101
1,191,583
3
95
TX
1,742
120
7%
106
3,577,756
3
81
6%
2,968
285.3
9%
102
19.1
4%
170
34.6
2%
113
16.4
8%
101
12.5
5%
241
21.8
Sources: ADA, BHPr, U.S. Census Bureau
*As of 6/30/01
Dentists in New York
New York State has 2,905 dentists in the cohort of recent dental graduates, or 10.7
percent of the national cohort. This number represents dentists who graduated from
dental school between 1993 and 1999, and had 2001 practice addresses in New York
State. Table 6.2 displays the dentists in this cohort for each New York State AHEC
region by the year of dental school graduation.
Table 6.2
Recent Dental Graduates Practicing in New York AHEC Regions in 2001
by Year of Dental School Graduation
New York State
Bronx-Westchester AHEC
Brooklyn-Queens-Long Island AHEC
Catskill-Hudson AHEC
Central New York AHEC
Erie-Niagara AHEC
Hudson-Mohawk AHEC
Northern AHEC
Manhattan-Staten Island AHEC
Western New York Rural AHEC
1993
1994
1995
1996
1997
1998
1999
426
33
201
15
19
20
15
1
97
25
422
46
191
17
15
24
16
4
90
19
406
25
185
14
19
29
14
2
105
13
433
25
164
19
21
19
15
4
151
15
458
36
161
14
21
28
11
1
166
20
353
27
162
12
11
25
6
3
97
10
407
22
165
9
9
34
9
3
148
8
Total
1993-99
2905
214
1229
100
115
179
86
18
854
110
While the Bronx-Westchester, Brooklyn-Queens-Long Island, Catskill-Hudson, Central
New York, Hudson-Mohawk, and Western New York AHECs appear to have fewer
dentists from the later graduating classes than from the earlier classes, Erie-Niagara and
Manhattan-Staten Island AHECs have both seen larger numbers among subsequent
graduating classes. Despite increasing numbers of dental graduates from New York
State dental schools, the number of dentists practicing in New York from subsequent
graduating classes has not increased during the study period.
39
Figure 6.1 presents the percentage of New York State dentists practicing in DHPSAs by
AHEC region. While seven percent of all dentists in the cohort practice in New York
State DHPSAs, this rate varied among the AHEC regions from no dentists in DHPSAs to
nearly forty percent.
Figure 6.1
Percentage of 1993-1999 Dental Graduates Practicing in Dental
HPSAs in 2001
New York State
7%
Bronx-Westchester AHEC 1%
Brooklyn-Queens-Long Island AHEC 1%
7%
Catskill-Hudson AHEC
Central New York AHEC
11%
Erie-Niagara AHEC
5%
Hudson-Mohawk AHEC
16%
Manhattan-Staten Island AHEC
Northern AHEC
39%
20%
Western New York AHEC
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
The distribution of dentists in primary care HPSAs was also examined and the percentage
of recent dental graduates practicing in HPSAs is presented in Figure 6.2. Despite
numbers of primary care HPSA designations and estimated underserved population that
are much higher than DHPSA designations, the distribution of dentists in primary care
HPSAs was slightly higher, but9 roughly comparable to that of DHPSAs.
Figure 6.2
Percentage of 1993-1999 Dental Graduates
Practicing in Primary Care HPSAs in 2001
9%
New York State
7%
Bronx-Westchester AHEC
Brooklyn-Queens-Long Island AHEC 3%
Catskill-Hudson AHEC
4%
Central New York AHEC
19%
Erie-Niagara AHEC 1%
Hudson-Mohawk AHEC 1%
Manhattan-Staten Island AHEC
19%
50%
Northern AHEC
12%
Western New York AHEC
0%
10%
20%
40
30%
40%
50%
60%
The recent graduate data was compared to the total number of registered dentists in each
AHEC region (see Table 6.3). Dentists must register a main office address with the State
Board of Dentistry every three years. Practicing dentists who graduated between 1993
and 1999 make up between 10 percent and 32 percent of the dental workforce in each
AHEC region. More urban AHEC regions were found to have a higher proportion of
recent graduate dentists.
Table 6.3
Total New York State Dentists and New Entrants by AHEC Region
Total Registered
Dentists*
Total New
Entrants
New Entrants As
Percent of Total
14,932
1,542
6,273
1,016
866
882
682
2,655
141
875
2,905
214
1,229
100
115
179
86
854
18
110
0.19
0.14
0.20
0.10
0.13
0.20
0.13
0.32
0.13
0.13
New York State
Bronx-Westchester AHEC
Brooklyn-Queens-Long Island AHEC
Catskill-Hudson AHEC
Central New York AHEC
Erie/Niagara AHEC
Hudson-Mohawk AHEC
Manhattan/Staten Island AHEC
Northern AHEC
Western New York Rural AHEC
*Registered with New York State Board of Dentistry as of 1/06/03
Thirty-four percent of dentists among New York’s new entrants are female (see Table
6.4), the same percentage found in the national cohort. This percentage is lower than the
percentage of female dental graduates during the study period, which was between 35 and
40 percent for each graduation year in the study cohort.22 New York State dental schools
had consistently higher percentages of female graduates than the national average during
this same time period, which is not reflected in the percentage of newly graduated female
dentists practicing in New York State.
Although there was mild fluctuation among various graduation cohorts, overall female
dentists were found to practice in DHPSAs at a slightly higher rate than male dentists.
While 7.4 percent of females had dental practices in DHPSAs, seven percent of males
did. On a national level, female dentists in this cohort also were found to practice in
DHPSAs at a slightly higher rate than males.
Table 6.4
Dentists in New York State AHECs in 2001 by Gender and Year of Graduation
1993
AHEC
New York State
Bronx-Westchester
Brooklyn-Queens-Long Island
Catskill-Hudson
Central New York
Erie/Niagara
Hudson-Mohawk
Manhattan/Staten Island
Northern
Western New York Rural
M
F
1994
M
F
1995
M
F
1996
M
F
1997
M
F
1998
M
F
1999
M
F
270 156 270 152 275 131 295 138 298 160 247 105 263 144
23 10 30 16 10 15 16
9
22 14 18
9
11 11
124 77 124 67 124 61 111 53 101 60 118 44 100 65
9
6
12
5
8
6
15
4
10
4
6
6
8
1
11
8
11
4
16
3
13
8
14
7
7
4
4
5
14
6
13 11 20
9
12
7
18 10 22
3
27
7
12
3
12
4
6
8
10
5
5
6
5
1
5
4
60 37 53 37 79 26 104 47 114 52 60 36 101 47
0
1
2
2
2
0
2
2
1
0
2
1
2
1
17
8
13
6
10
3
12
3
13
7
9
1
5
3
41
Percent
Female
34%
39%
35%
32%
34%
30%
36%
33%
39%
28%
Dental Practice Characteristics
The dental data were further analyzed by dental practice characteristics to provide a
gauge for the dental services available in each AHEC region. Table 6.5 provides the
number of recent dental graduates in each of ten primary dental occupations. Seventy
percent of dentists in New York State are private practitioners working over 30 hours per
week, with an additional 7 percent in private practice working fewer than 30 hours per
week. Nationally, 74 percent of dentists in this cohort are in private practice working
over 30 hours per week and another 6 percent work fewer than 30 hours per week. New
York has a smaller percentage of dentists employed in the armed forces and a higher
percentage of dentists who identified themselves as graduate students/residents or
hospital staff dentists than the nation as a whole.
Table 6.5.
Primary Occupation of Recent Dental Graduates in New York State in 2001
AHEC
New York State
Bronx-Westchester
Brooklyn-Queens-LI
Catskill-Hudson
Central New York
Erie-Niagara
Hudson-Mohawk
Manhattan-SI
Northern
Western NY Rural
Private Private Dental
Other State/
Grad
Other
Other
Not in
Practice Practice School Armed Federal Local Hospital Student/ Non-dental
Health/
Practice/
>30 Hrs <30 Hrs Faculty Forces Service Govt
Staff
Resident Student Dental Staff Other
2035
123
866
69
88
112
66
621
12
78
198
23
88
5
2
20
7
48
1
4
39
1
12
0
0
3
0
21
0
2
25
1
5
4
2
1
1
7
1
3
20
1
4
3
1
3
1
4
2
1
9
0
2
0
2
2
0
2
1
0
52
6
19
5
3
6
0
11
0
2
479
55
210
9
12
31
10
132
1
19
3
0
2
0
0
0
0
1
0
0
42
4
19
4
5
1
1
7
0
1
The overwhelming majority of dentists in New York (94%) and the nation (93.3%)
practice general dentistry. Ten percent or more of the dentists in the national dataset who
are in the specialties of general practice, pedodontics, periodontics, and prosthodontics
practice in New York State. Table 6.6 provides a breakdown of dentists by specialty in
each New York AHEC region.
Most AHECs have a proportion of general practice dentists close to that of the statewide
average. In the Northern AHEC, all dentists whose specialty is known are general
practice dentists. Only in the Western New York Rural AHEC are fewer than 90 percent
of dentists in general practice. In that AHEC, 86 percent are general practice dentists. In
several AHECs, particularly Catskill-Hudson, Central New York, and the Northern
AHEC, there are no practitioners in several dental specialties among the recent
graduation cohort. For example, in four AHECs there are no oral surgeons who
graduated within the past ten years.
42
3
0
2
1
0
0
0
0
0
0
Table 6.6
Recent Dental Graduates Practicing in New York State AHEC Regions in 2001 by Specialty
AHEC
General
Oral
Endo- Ortho- Pedo- Perio- ProsthoOral
Public Specialty
Practice Surgery dontics dontics dontics dontics dontics Pathology Health Unknown
New York State
Bronx-Westchester
Brooklyn-Queens-SI
Catskill-Hudson
Central New York
2695
193
1156
96
105
17
2
9
0
0
14
2
1
0
2
30
3
11
0
2
51
4
20
0
3
28
4
10
2
0
29
2
11
1
1
1
0
0
0
0
1
0
1
0
0
39
4
10
1
2
Erie-Niagara
Hudson-Mohawk
Manhattan-Staten Island
Northern
Western New York Rural
157
77
800
17
94
1
1
4
0
0
1
0
5
0
3
5
3
2
0
4
7
1
11
0
5
1
2
9
0
0
1
0
10
0
3
1
0
0
0
0
0
0
0
0
0
5
2
13
1
1
Discussion
The data on recent dental graduates indicates the same or fewer dentists from later dental
school graduating classes practicing in most AHEC regions, despite increases in the
population and increases in the number of graduates from dental schools in New York
State. While some AHEC regions, Manhattan-Staten Island most notably, have attracted
larger numbers of recent graduates relative to their populations and total dental
workforce, others have smaller numbers of recently graduated dentists entering the dental
workforce.
In a nationwide analysis of the dental data, substantial variation was found in the
percentage of recent dental graduates practicing in dental HPSAs (14.5 percent) and those
in primary care HPSAs (6 percent).1 In New York State, the proportion of dentists
practicing in DHPSAs varies widely between AHEC regions and, as in the rest of the
nation, appears to be a function of the DHPSA designations in each region. However, the
distribution of recent dental graduates in dental HPSAs is similar to that of dentists’
distribution in primary care HPSAs in New York State.
New York has taken several steps to increase access to dental services in the state. To
increase the number of dentists in the state, a law was passed which allows foreign
citizens to practice dentistry in New York State for up to nine years, provided they meet
all other requirements and that they practice in a DHPSA.23 It is too early to tell whether
this provision will have an impact on the dental workforce in New York’s DHPSAs.
In response to a lawsuit by the Dental Society of the State of New York several years
ago, an agreement was made between New York State and the Society which stipulated
that incremental increases be made to the Medicaid dental payment rates over a period of
three years beginning in 2000. A fourth increase was to be contingent upon reaching
goals for dentist enrollments in Medicaid and dental visits for Medicaid-insured patients.
These goals were not reached and a fourth rate increase was not provided.
43
Dental care for disadvantaged populations has been described as a “bona fide public
health problem.”24 Both dental workforce issues, particularly ensuring an adequate
dental workforce in more rural parts of the state, and dental access issues, including
increasing participation in the Medicaid program, must be addressed to ensure adequate
dental services for all New Yorkers.
44
1
A Study to Estimate the Proportion of Health Care Practitioners Practicing in Underserved Areas was
submitted to HRSA, Bureau of Health Professions in December 2003.
2
A Study of Physician Distribution in Health Professional Shortage Areas was submitted to HRSA in May
2004.
3
Selected Statistics on Health Professional Shortage Areas As of June 30, 2001. HRSA, Bureau of Health
Professions, Division of Shortage Designation. Rockville, MD.
4
Physician Characteristics and Distribution in the U.S.: 2002-2003 Edition, American Medical
Association. Chicago, IL
5
Selected Statistics on Health Professional Shortage Areas as of June 30, 2001. HRSA, Bureau of Health
Professions, Division of Shortage Designation. Rockville, MD.
6
U.S. Bureau of the Census, State and County Quickfacts, accessed at www.census/quickfacts/gov.on
3/2/04.
7
New York State Education Department Office of the Professions, Medicine-Licensee Statistics, accessed
at www.op.nysed.gov/medcounts.htm on 2/23/04.
8
The Registered Nurse Population: Findings from The National Sample Survey of Registered Nurses.
HRSA, BHPr, Division of Nursing, March 1992.
9
Pearson, L., “Annual Legislative Update,” The Nurse Practitioner 26;1:7-16.
10
New York State Registered Nursing Graduates, 1996-2004. The Center for Health Workforce Studies,
SUNY @ Albany. January 2003.
11
New York State counts of licensed professionals are available at http://op.nysed.gov/04reg.htm.
Accessed on 4/9/04.
12
Data maintained by the American College of Nurse Midwives available at
http://midwife.org/prf/display.cfm. Accessed on 4/9/04.
13
AANA Membership Services
14
Fallacaro, MD, “An Inefficient Mix: A Comparative Analysis of Nurse and Physician Anesthesia
Providers Across New York State,” Journal of the New York State Nurses Association, June 1998, Vol.29;
No.2.
15
Fallacaro, M.D., Obst, T.E., Gunn, I.P., et.al., “The national distribution of Certified Registered Nurse
Anesthetists across metropolitan and nonmetropolitan settings,” Journal of the American Association of
Nurse Anesthetists. June 1996;64;3:237-242.
16
Fallacaro, M, “The Practice and Distribution of Certified Registered Nurse Anesthetists in Federally
Designated Nurse Shortage Areas.” CRNA;8;55-61.
17
Selected Statistics on Health Professional Shortage Areas As of June 30, 2001. Division of Shortage
Designation, Bureau of Primary Health Care, HRSA.
18
National Oral Health Surveillance System, Centers for Disease Control. Available at cdc.gov.nohss
19
Michael Berry, National Health Service Corps Program Office, HRSA. Personal communication, August
12, 2003.
20
Registration Counts by County by Profession: 1/06/03, New York State Office of the Professions,
Division of Professional Licensing Services.
21
Dental Health Professional Shortage Area Methodology: A Critical Review. UCSF Center for California
Health Workforce Studies. October 2002.
22
1999/2000 Survey of Predoctoral Dental Education: Academic Programs, Enrollment, and Graduates.
Volume I. American Dental Association. March 2001. Chicago, IL.
23
See general description at http://www.op.nysed.gov/dentlimlic.htm.
24
Claude Earl Fox, HRSA Administrator, in “Report of “AIM for Change” in Medicaid Conference,
sponsored by the American Dental Association , August 2-3, 1999.
45