The Dartmouth Atlas of Health Care. The Middle Atlantic States. The Center for the Evaluative Clinical Sciences. Dartmouth Medical School

Transcription

1 The Dartmouth Atlas of Health Care The Middle Atlantic States The Center for the Evaluative Clinical Sciences Dartmouth Medical School AHA books are published by American Hospital Publishing, Inc., an American Hospital Association company

2 The views expressed in this publication are strictly those of the authors and do not necessarily represent official positions of the American Hospital Association. Library of Congress Cataloging-in-Publication Data Dartmouth Medical School. Center for the Evaluative Clinical Sciences. The Dartmouth atlas of health care / the Center for the Evaluative Clinical Sciences, Dartmouth Medical School. p. cm. ISBN (softcover) 1. Medical care United States Marketing Maps. 2. Health facilities United States Statistics. I. Title. G1201.E5D (G&M) 362.1'0973'022 dc CIP MAP Catalog no The Trustees of Dartmouth College All rights reserved. The reproduction or use of this book in any form or in any information storage or retrieval system is forbidden without the express written permission of the publisher. Printed in the USA

3 The Dartmouth Atlas of Health Care in the Middle Atlantic States John E. Wennberg, M.D., M.P.H., Principal Investigator and Series Editor Megan McAndrew Cooper, M.B.A., M.S., Editor and other members of the Dartmouth Atlas of Health Care Working Group Co-investigators and Researchers Thomas A. Bubolz, Ph.D. Elliott S. Fisher, M.D., M.P.H. Alan M. Gittelsohn, Ph.D. David C. Goodman, M.D., M.S. Jack E. Mohr James F. Poage, Ph.D. Sandra M. Sharp, S.M. Jonathan S. Skinner, Ph.D. Thérèse A. Stukel, Ph.D. Administration, Data Production, and Technical Support Kristen K. Bronner, M.A. Nancy E. Cloud Jiaqi Gong, M.S. Katherine W. Herbst, M.S.

4 For Daniel F. Hanley, M.D. and David N. Soule warriors for small area analysis

5 The research to create the Dartmouth Atlas of Health Care was made possible by a grant from The Robert Wood Johnson Foundation

6 vi The Center for the Evaluative Clinical Sciences Dartmouth Medical School Hanover, New Hampshire (603) Other publications in this series The Dartmouth Atlas of Health Care in the United States The Dartmouth Atlas of Health Care in the New England States The Dartmouth Atlas of Health Care in the South Atlantic States The Dartmouth Atlas of Health Care in the Great Lakes States The Dartmouth Atlas of Health Care in the East South Central States The Dartmouth Atlas of Health Care in the Great Plains States The Dartmouth Atlas of Health Care in the West South Central States The Dartmouth Atlas of Health Care in the Mountain States The Dartmouth Atlas of Health Care in the Pacific States Published in cooperation with The Center for Health Care Leadership of the American Hospital Association American Hospital Publishing, Inc. Chicago, Illinois

7 vii Table of Contents Map List: x Figure List: xii Introduction: Geographic Variations in Health Care 1 About Benchmarking in the Atlas 5 Tables 7 Strategies and Methods 7 About Rates in the Atlas 8 Making Fair Comparisons Between Hospital Service Areas 9 Communicating With Us About the Atlas 10 Part One: The Geography of Health Care in the Middle Atlantic States 11 The Geography of Health Care in the Middle Atlantic States 12 Reference Maps: Hospital Service Areas in the Middle Atlantic States 14 Part Two: Acute Care Hospital Resources and Expenditures in the Middle Atlantic States 41 Acute Care Hospital Beds 42 Acute Care Hospital Employees 44 Registered Nurses Employed in Acute Care Hospitals 46 Total Acute Care Hospital Expenditures 48 Benchmarking: Acute Care Hospital Beds 50 Benchmarking: Hospital Employees 52 Benchmarking: Hospital-Based Registered Nurses 54 Benchmarking: Total Hospital Expenditures 56 Table 2. Acute Care Hospital Resources Allocated to Hospital Service Areas 59

8 viii THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Part Three: The Medicare Program in the Middle Atlantic States 63 Medicare Reimbursements for Traditional (Noncapitated) Medicare 66 Medicare Reimbursements for Professional and Laboratory Services 68 Medicare Reimbursements for Inpatient Hospital Services 70 Medicare Reimbursements for Outpatient Facilities 72 Average Adjusted Per Capita Costs 74 Medicare Enrollment in Capitated Managed Care 76 The Boundaries of Counties, Hospital Service Areas, and the AAPCC 78 Benchmarking: Total Medicare Reimbursements 80 Benchmarking: Reimbursements for Professional and Laboratory Services 82 Benchmarking: AAPCC 84 Table 3. Medicare Reimbursements per Enrollee by Program Components ( ) and Adjusted Average Per Capita Cost (1996) for Hospital Service Areas 89 Part Four: The Physician Workforce in the Middle Atlantic States 97 The Physician Workforce Active in Patient Care 98 Specialist Physicians 100 Physicians in Primary Care 102 Benchmarking: The Physician Workforce Active in Patient Care 104 Benchmarking: Specialists 106 Benchmarking: Primary Care Physicians 108 Table 4. Physicians in Active Practice Serving Residents of Hospital Service Areas (Physicians per 100,000 population, 1993) 111 Part Five: The Utilization of Hospitals for Medical and Surgical Conditions 113 Total Medicare Discharges 116 Medicare Discharges for Medical Conditions 118 Medicare Discharges for Surgical Procedures 120 Medicare Discharges for High Variation Medical Conditions 122 Contribution of Discharge Rate and Average Length of Stay to Patient Days of Hospitalization for High Variation Medical Conditions 124 Benchmarking: Discharges for Surgical Procedures 126 Benchmarking: Discharges for High Variation Medical Conditions 128 Coronary Artery Bypass Grafting 130 Rates of Coronary Angiography and Rates of CABG and PTCA 130 Percutaneous Transluminal Coronary Angioplasty 132 Coronary Angiography 134 Back Surgery 136

9 TABLE OF CONTENTS ix Transurethral Resection of the Prostate for Benign Prostatic Hyperplasia 138 Benchmarking: Coronary Artery Bypass Grafting 140 Benchmarking: Coronary Angiography 142 Table 5. Hospitalizations for Total, Surgical, Medical and High Variation Medical Conditions and Selected Diagnostic and Surgical Procedures in Hospital Service Areas per 1,000 Medicare Enrollee Person-Years ( ) 145 Part Six: Hospital Bed Allocation and Medicare Reimbursements for Inpatient Services by Hospital Service Area and Hospital by Location 153 Table 6. Hospital Bed Allocation and Medicare Reimbursements for Inpatient Services by Hospital Service Area and Hospital by Location 163

10 x THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Maps NUMBER MAP TITLE PAGE 1.1 Buffalo, New York 1.2 Rochester, New York 1.3 Syracuse, New York 1.4 Binghamton and Elmira, New York 1.5 Albany, New York 1.6 Ridgewood, New Jersey and White Plains, New York 1.7 Bridgeport, Hartford, and New Haven, Connecticut 1.8 East Long Island, New York 1.9 New York, New York 1.10 Bronx, New York (detail) 1.11 Hackensack and Paterson, New Jersey 1.12 Newark, New Jersey 1.13 Morristown, New Jersey 1.14 New Brunswick, New Jersey 1.15 Camden, New Jersey 1.16 Wilmington, Delaware 1.17 Philadelphia, Pennsylvania 1.18 Lancaster and Reading, Pennsylvania 1.19 Allentown, Pennsylvania 1.20 Scranton and Wilkes-Barre, Pennsylvania 1.21 Danville and Sayre, Pennsylvania 1.22 Harrisburg and York, Pennsylvania 1.23 Altoona and Johnstown, Pennsylvania 1.24 Pittsburgh, Pennsylvania 1.25 Pittsburgh, Pennsylvania (detail) 1.26 Erie, Pennsylvania

11 MAPS xi 2.1 Acute Care Hospital Beds 2.2 Acute Care Hospital Employees 2.3 Registered Nurses Employed in Acute Care Hospitals 2.4 Total Acute Care Hospital Expenditures Price Adjusted Reimbursements for Traditional (Noncapitated) Medicare 3.2 Price Adjusted Medicare Reimbursements for Professional and Laboratory Services 3.3 Price Adjusted Medicare Reimbursements for Inpatient Hospital Services 3.4 Price Adjusted Medicare Reimbursements for Outpatient Services 3.5 AAPCC 3.6 Medicare Enrollment in Capitated Managed Care Plans 3.7 Suffolk County, New York The Physician Workforce Active in Patient Care 4.2 Specialist Physicians 4.3 Physicians in Primary Care 5.1 Total Discharges per 1,000 Medicare Enrollees 5.2 Medical Discharges per 1,000 Medicare Enrollees 5.3 Surgical Discharges per 1,000 Medicare Enrollees 5.4 Discharges for High Variation Medical Conditions 5.11 Coronary Artery Bypass Grafting 5.12 Percutaneous Transluminal Coronary Angioplasty 5.13 Coronary Angiography 5.14 Back Surgery 5.15 Transurethral Resection of the Prostate for Benign Prostatic Hyperplasia

12 xii THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Figures NUMBER FIGURE TITLE 1.1 Acute Care Hospital Beds in Selected Hospital Service Areas in the New England States Compared to the Boston and New Haven Hospital Service Areas and to the U.S. Average (1993) 2.1 Acute Care Hospital Beds Allocated to Hospital Service Areas in the Middle Atlantic States (1993) 2.2 Hospital Employees Allocated to Hospital Service Areas in the Middle Atlantic States (1993) 2.3 Hospital-Based Registered Nurses Allocated to Hospital Service Areas in the Middle Atlantic States (1993) 2.4 Price Adjusted Acute Care Hospital Expenditures Allocated to Hospital Service Areas in the Middle Atlantic States (1993) 2.5 Acute Care Hospital Beds Allocated to Selected Hospital Service Areas in the Middle Atlantic States Compared to the Highest and Lowest Ranked Selected Areas (1993) 2.6 Acute Care Hospital Beds Allocated to Selected Hospital Service Areas in the Middle Atlantic States Compared to Selected Hospital Service Areas Elsewhere in the U.S. (1993) 2.7 Hospital Employees Allocated to Selected Hospital Service Areas in the Middle Atlantic States Compared to Highest and Lowest Ranked Selected Areas (1993) 2.8 Hospital Employees Allocated to Selected Hospital Service Areas in the Middle Atlantic States Compared to Selected Hospital Service Areas Elsewhere in the U.S. (1993) 2.9 Hospital-Based Registered Nurses Allocated to Selected Hospital Service Areas in the Middle Atlantic States Compared to Highest and Lowest Ranked Selected Areas (1993) 2.10 Hospital-Based Registered Nurses Allocated to Selected Hospital Service Areas in the Middle Atlantic States Compared to Selected Hospital Service Areas Elsewhere in the U.S. (1993) 2.11 Price Adjusted Total Hospital Expenditures per capita in Selected Hospital Service Areas in the Middle Atlantic States Compared to Highest and Lowest Ranked Selected Hospital Service Areas (1993) PAGE

13 FIGURES xiii 2.12 Price Adjusted Total Hospital Expenditures per capita in Selected Hospital Services Areas in the Middle Atlantic States Compared to Selected Hospital Service Areas Elsewhere in the U.S. (1993) 3.1 Price Adjusted Reimbursements for Traditional (Noncapitated) Medicare in Hospital Service Areas ( ) 3.2 Price Adjusted Part B Medicare Reimbursements for Professional and Laboratory Services In Hospital Service Areas ( ) 3.3 Price Adjusted Medicare Reimbursements for Inpatient Hospital Services per Medicare Enrollee in Hospital Service Areas ( ) 3.4 Price Adjusted Medicare Reimbursements for Outpatient Services In Hospital Service Areas ( ) 3.5 The Adjusted Average per Capita Cost in Hospital Service Areas in the Middle Atlantic States (1996) 3.6 Price Adjusted Total Reimbursements per Medicare Enrollee in Selected Hospital Service Areas in the Middle Atlantic States Compared to Highest and Lowest Ranked Selected Areas ( ) 3.7 Price Adjusted Total Reimbursements per Medicare Enrollee in Selected Hospital Services Areas in the Middle Atlantic States Compared to Selected Hospital Service Areas Elsewhere in the U.S. ( ) 3.8 Price Adjusted Total Reimbursements for Professional and Laboratory Services per Medicare Enrollee in Selected Hospital Service Areas in the Middle Atlantic States Compared to Highest and Lowest Ranked Selected Areas ( ) 3.9 Price Adjusted Total Reimbursements for Professional and Laboratory Services per Medicare Enrollee in Selected Hospital Service Areas in the Middle Atlantic States Compared to the Selected Hospital Service Areas Elsewhere in the U.S. ( ) 3.10 AAPCC in Selected Hospital Service Areas in the Middle Atlantic States Compared to the Highest and Lowest Ranked Selected Areas (1996). The AAPCC is Not Adjusted for Price Differences Price Adjusted AAPCC in Selected Hospital Service Areas in the Middle Atlantic States Compared to Highest and Lowest Ranked Selected Areas (1996) 3.12 AAPCC in Selected Hospital Service Areas in the Middle Atlantic States Compared to Selected Hospital Service Areas Elsewhere in the U.S. (1996). The AAPCC is Not Adjusted for Price Differences Price Adjusted AAPCC in Selected Hospital Service Areas in the Middle Atlantic States Compared to Selected Hospital Service Areas Elsewhere in the U.S. (1996) 4.1 Physicians Allocated to Hospital Service Areas (1993) 4.2 Specialists Allocated to Hospital Service Areas (1993) 4.3 Primary Care Physicians Allocated to Hospital Service Areas (1993)

14 xiv THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES 4.4 The Total Physician Workforce Allocated to Selected Hospital Service Areas in the Middle Atlantic States Compared to the Highest and Lowest Ranked Selected Areas (1993) 4.5 The Total Physician Workforce Allocated to Selected Hospital Service Areas in the Middle Atlantic States Compared to Selected Hospital Service Areas Elsewhere in the U.S. (1993) 4.6 Specialist Physicians Allocated to Selected Hospital Service Areas in the Middle Atlantic States Compared to the Highest and Lowest Ranked Selected Areas (1993) 4.7 Specialist Physicians Allocated to Selected Hospital Service Areas in the Middle Atlantic States Compared to Selected Hospital Service Areas Elsewhere in the U.S. (1993) 4.8 Primary Care Physicians Allocated to Selected Hospital Service Areas in the Middle Atlantic States Compared to the Highest and Lowest Ranked Selected Areas (1993) 4.9 Primary Care Physicians Allocated to Selected Hospital Service Areas in the Middle Atlantic States Compared to Selected Hospital Service Areas Elsewhere in the U.S. (1993) 5.1 All Discharges per 1,000 Medicare Enrollees in Hospital Service Areas in the Middle Atlantic States ( ) 5.2 Medical Discharges per 1,000 Medicare Enrollees in Hospital Service Areas in the Middle Atlantic States ( ) 5.3 Surgical Discharges per 1,000 Medicare Enrollees in Hospital Service Areas in the Middle Atlantic States ( ) 5.4 Discharges for High Variation Medical Conditions per 1,000 Medicare Enrollees in Hospital Service Areas in the Middle Atlantic States ( ) 5.5 The Relationship Between Total Hospital Days and Discharge Rate for High Variation Medical Conditions in Hospital Service Areas in the Middle Atlantic States ( ) 5.6 The Relationship Between Total Hospital Days and Average Length of Stay (in Days) for High Variation Medical Conditions in Hospital Service Areas in the Middle Atlantic States ( ) 5.7 Discharges for Surgical Procedures per 1,000 Medicare Enrollees in Selected Hospital Service Areas in the Middle Atlantic States Compared to the Highest and Lowest Ranked Selected Hospital Service Areas ( ) 5.8 Discharges for Surgical Procedures per 1,000 Medicare Enrollees in Selected Hospital Service Areas in the Middle Atlantic States Compared to Selected Hospital Service Areas Elsewhere in the U.S. ( ) 5.9 Discharges for High Variation Medical Conditions per 1,000 Medicare Enrollees in Selected Hospital Service Areas in the Middle Atlantic States Compared to the Highest and Lowest Ranked Selected Hospital Service Areas ( )

15 FIGURES xv 5.10 Discharges for High Variation Medical Conditions per 1,000 Medicare Enrollees in Hospital Service Areas in the Middle Atlantic States Compared to Selected Hospital Service Areas Elsewhere in the U.S. ( ) 5.11 Rates of Coronary Artery Bypass Grafting Procedures per 1,000 Medicare Enrollees in Hospital Service Areas in the Middle Atlantic States ( ) 5.12 Rates of Percutaneous Transluminal Coronary Angioplasty Procedures per 1,000 Medicare Enrollees in Hospital Service Areas in the Middle Atlantic States ( ) 5.13 The Association Between Rates of Coronary Angiography and the Combined Rates of Coronary Artery Bypass Grafting and Percutaneous Transluminal Coronary Angioplasty Procedures per 1,000 Medicare Enrollees in Hospital Service Areas in the Middle Atlantic States ( ) 5.14 Rates of Back Surgery Procedures per 1,000 Medicare Enrollees in Hospital Service Areas in the Middle Atlantic States ( ) 5.15 Rates of Transurethral Resection of the Prostate for Benign Prostatic Hyperplasia per 1,000 Male Medicare Enrollees Allocated to Hospital Service Areas in the Middle Atlantic States ( ) 5.16 CABG Procedures per 1,000 Medicare Enrollees In Selected Hospital Service Areas in the Middle Atlantic States Compared to the Highest and Lowest Ranked Selected Hospital Service Areas ( ) 5.17 CABG Procedures per 1,000 Medicare Enrollees In Selected Hospital Service Areas in the Middle Atlantic States Compared to Selected Hospital Service Areas Elsewhere in the U.S. ( ) 5.18 Angiography Procedures per 1,000 Medicare Enrollees In Selected Hospital Service Areas in the Middle Atlantic States Compared to the Highest and Lowest Ranked Selected Hospital Service Areas ( ) 5.19 Angiography Procedures per 1,000 Medicare Enrollees in Selected Hospital Service Areas in the Middle Atlantic States Compared to Selected Hospital Service Areas Elsewhere in the U.S. ( )

16 xvi THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Tables NUMBER TITLE PAGE 1 Common Conditions for Which a Number of Treatment Alternatives Are Used 2 Acute Care Hospital Resources Allocated to Hospital Service Areas 3 Medicare Reimbursements per Enrollee by Program Components ( ) and Adjusted Average Per Capita Cost (1996) for Hospital Service Areas 4 Physicians in Active Practice Serving Residents of Hospital Service Areas (Physicians per 100,000 population, 1993) 5 Hospitalizations for Total, Surgical, Medical and High Variation Medical Conditions and Selected Diagnostic and Surgical Procedures in Hospital Service Areas per 1,000 Medicare Enrollee Person-Years ( ) 6 Hospital Bed Allocation and Medicare Reimbursements for Inpatient Services by Hospital Service Area and Hospital by Location

17 Introduction

18 2 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Geographic Variations In Health Care The national volume of the Dartmouth Atlas of Health Care, published in the Spring of 1996, brought to light the often startling patterns of variation in health care throughout the nation. Research conducted to produce the Atlas revealed large differences in the rates of allocation of hospital resources, in the physician supply, and in the use of procedures such as coronary artery bypass grafting. The analysis of these differences was at the level of 306 hospital referral regions the natural markets, defined by patient origin studies, for the use of tertiary, or referral, care among populations in the United States. But health care is highly local, and the analysis of patterns of resource distribution and utilization among referral regions often masks important differences between the communities which, when aggregated, make up the larger region. Moreover, the task of actually addressing the problems of variation is often a local undertaking, one for which more specific and more local information is needed. The 306 hospital referral regions comprise 3,436 geographically distinct hospital service areas, which are the natural markets for care that can be delivered locally outpatient services and most acute hospital care. The regional volumes of the Dartmouth Atlas of Health Care (this book is one of nine such volumes) focus on these hospital service areas as the unit of analysis. The regional volumes make clear that there is often as much, and frequently more, variation among the hospital service areas within states and regions than among the larger units of analysis, the hospital referral regions. The existence of variation raises a number of important issues. Foremost is the question Which rate is right? Which pattern of resource allocation, and which pattern of utilization, is correct? The study of practice variations reveals how complex this question really is. In the case of variations in rates of individual procedures, such as coronary artery bypass grafting and back surgery, the explanation is not that patients in areas with low procedure rates are going without treatment; they are, instead,

19 INTRODUCTION 3 being treated differently, often with more conservative medical management (Table 1). Learning which rate is right requires learning what informed patients want. The right rate must be the one that reflects the choices of patients who have been adequately informed and empowered to choose among the available options. Table 1. Common Conditions for Which a Number of Treatment Alternatives Are Used Condition Noncancerous conditions of the uterus Angina pectoris Major Treatment Alternatives Surgery (by type;) hormone treatment; drugs; watchful waiting Bypass surgery; angioplasty; drugs Gallstones Surgery; stone crushing; medical management; watchful waiting Peripheral vascular disease Bypass surgery; angioplasty; medical management Cataracts Lens extraction (by type); watchful waiting Arthritis of hip and knee Surgery (by type); medical management Prostatism (BPH benign prostatic hyperplasia) Herniated disc Surgery (by type); balloon dilation; drugs; microwave diathermy; watchful waiting Surgery (by type); various medical management strategies Atherosclerosis of carotid artery with threat of stroke Carotid endarterectomy; aspirin

20 4 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES In the case of variations in the supply of health care resources, such as the numbers of hospital beds and physicians, the question Which rate is right? needs to be framed in another way: What is the impact on population health of variations in resource allocation? Is more better? And if not, how much could be reallocated to other, more effective uses by reducing resources and their utilization to the level of more conservative communities? Another important issue raised by geographic variation concerns fairness. Variation studies provide good evidence that populations in regions where health care spending is low are not necessarily sicker, or have greater unmet medical need, than those in regions where spending is high. Spending is higher, not because better health is being achieved, but because the local health care systems have greater capacity, or because the price of medical care in those communities is higher. A system that rewards high spending areas by continuing to pay their higher costs is by definition economically punishing areas that have fewer resources, use them more efficiently, and are reimbursed less. Is it fair for citizens living in regions with low per capita health care spending to subsidize the greater (and more costly) use of care by people living in high resource and high utilization regions? The nine regional Atlases provide the data and analysis for specific hospital service areas with which these and other questions can be addressed. Strategies to address the question of the appropriate levels of supply must be developed in the absence of detailed understanding of the nature of health care needs, medical care outcomes, and what patients want. One such strategy begins by examining individual communities and comparing them to others. Such comparisons lead naturally to a search for efficiently operated health plans or communities those with an adequate but not excessive supply of resources.

21 INTRODUCTION 5 About Benchmarking in the Atlas Even in the absence of a detailed understanding of the nature of health care needs, medical care outcomes, and what patients want, we must establish appropriate levels of supply. One method of doing this is to examine the way resources are actually used, and to use as benchmarks efficiently operated health care plans or communities that appear to have an adequate but not excessive level of supply. Benchmarking provides answers to two related questions: How much more (or less) health care capacity would the nation need, if all areas had the level of capacity of the benchmark area? And how much more (or less) health care capacity would be required in a specific area if its per capita capacity were equal to the level of the benchmark area? Figure 1.1 illustrates the benchmarking approach to the second question by comparing the supply of acute care hospital beds per thousand residents of Boston, Massachusetts, Hartford, Connecticut, and New Haven, Connecticut, to three benchmarks. The benchmarks in this example are the highest ranked of the three areas, Boston (which had 3.7 beds per thousand residents in 1993); New Haven, the lowest ranked (2.4 beds per thousand) and the United States average of 3.3 beds per thousand. The figure shows the result of applying the New Haven benchmark to Boston: Boston s adjusted bed supply was 54% higher than New Haven s (3.712/ 2.404= 1.54). If the New Haven rate were applied in Boston, Boston would have had 1,006 fewer beds (the number in parentheses). This number is obtained by multiplying the population of the Boston hospital service area by its bed rate: x 768,694 = 2, Had New Haven rates applied, the number allocated would have been 1,847.9 (2.404 x 768,694). The excess beds in Boston are calculated by subtraction: 2, ,847.9 = 1, In Figure 1.1, Hartford, Connecticut s, adjusted rates are demonstrated to have been 23% higher than the New Haven benchmark; the surplus is calculated as 288 acute care beds in the Hartford hospital service area. Figure 1.1 also benchmarks Boston s

22 6 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Figure 1.1. Allocated Acute Care Hospital Beds in Selected Hospital Service Areas in the New England States Compared to the Boston, Massachusetts and New Haven, Connecticut Hospital Service Areas and to the U.S. Average (1993) Benchmarks are used in this volume of the Atlas to compare levels of supply of health care resources, reimbursements, and utilization among hospital service areas in the Middle Atlantic States. These comparisons are starting points; using the Dartmouth Atlas of Health Care databases, which are available on CD-ROM, and software available without charge through the Atlas internet site ( it is possible to compare any given hospital service area to any other area, and, in the case of the physician workforce, to a large health maintenance organization. level of bed supply to Hartford s and New Haven s. Hospital bed rates in Hartford were 20% lower than in Boston; when the Boston benchmark is applied to Hartford, 381 more beds are needed. If Boston s rate were applied to New Haven, 506 more hospital beds would be needed. The figure also illustrates the use of the United States average as a benchmark.

23 INTRODUCTION 7 Tables Detailed information about each hospital service area in the Middle Atlantic States, including most of the variables presented in the Atlas, is presented at the end of Parts Two through Five. Part Six presents details concerning the contribution of specific hospitals to the total allocation of hospital beds and Medicare reimbursements for inpatient care in each hospital service area. It also includes information on the number of physicians who serve each hospital service area and the locations of their practices. A more extensive database is available on CD-ROM. Strategies and Methods Part Nine of the national volume of the Dartmouth Atlas of Health Care provides details about the methods used in the Atlas and an explanation of the distribution graphs and the measure of association, the R 2 statistic, used in both the national and regional Atlases. Since some hospital service areas have small populations, areas were excluded from maps and figures in the regional volumes if the standard error of their rates exceeded 10% of the national average rate; for surgical procedures, the maximum standard error was 20%. The minimum population size for inclusion thus differs among the variables, and is reported in the notes to Tables Two through Five. The impact of sample size is greatest for the estimates of Medicare reimbursements, which are based on a 5% sample of Medicare claims. In the national volume, these estimates were based on a one-year sample (1993). To increase the precision of these estimates, the data for reimbursements presented in the regional Atlases are based on a two-year sample ( ); the denominators are the enrollee person-years for the same time period. The rates thus reflect the average annual rate for the two-year period,

24 8 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES About Rates in the Atlas In order to make comparisons easier, all rates in the Atlas are expressed on a scale that results in at least one digit to the left of the decimal point (e.g., 98.4 primary care physicians per hundred thousand residents, rather than.984 per thousand). To achieve this, different denominators were used in calculating rates. The levels of supply of hospital beds and hospital full time equivalent employees and registered nurses are expressed as beds, employees, and registered nurses per thousand residents of the hospital service area, based on American Hospital Association data and census calculations. Expenditures and reimbursements are expressed as dollars per capita or per Medicare enrollee, based on American Hospital Association data, Medicare claims data, and census calculations. The numbers of physicians providing services to residents of hospital service areas are expressed as physicians per hundred thousand residents, based on American Medical Association and American Osteopathic Association data and census calculations. The numbers of surgical and diagnostic procedures performed are expressed as procedures per thousand Medicare enrollees in the hospital service area, (or as procedures per thousand male Medicare enrollees in the area, in the case of prostate procedures) based on Medicare claims data. Patient day rates are expressed as total inpatient days per thousand Medicare enrollees, based on Medicare claims data.

25 INTRODUCTION 9 Making Fair Comparisons Between Hospital Service Areas Some communities have greater needs for health care services and resources than others; for example, in some communities in Florida, as many as 60% of residents are over age 65. Other areas including some with large college populations, or ski resorts have much larger proportions of younger people. To ensure fair comparisons between areas, all rates in the Atlas have been adjusted to remove the differences that might be due to the different age and sex composition of local populations. This adjustment avoids identifying some areas as having high rates of utilization simply because of their larger proportions of elderly residents. When data were available, rates have also been adjusted for differences in race. The methods used to adjust these rates are explained in Part Nine of the national volume of the Dartmouth Atlas of Health Care. Some areas, such as major urban centers, have higher costs of living than others. Such areas are likely to have high health care expenditures because the costs of personnel, real estate, and supplies are higher, and not necessarily because they are providing more services. Adjusting for such variation provides a more comparable measure of differences in real health care spending that is not simply due to differences in costs of living among areas. To ensure fair comparisons of health care expenditures, hospital expenditure rates and Medicare reimbursement rates were adjusted to take into account the differences between hospital service areas in costs of living. The methods used to adjust for age, sex, race, and price of medical care are detailed in Part Nine of the national volume of the Dartmouth Atlas of Health Care.

26 10 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Communicating With Us About the Atlas Our Atlas Home Page on the World Wide Web contains Atlas information, including a summary of Dartmouth related research and electronic copies of some hard-to-find references. Please send us your comments on the Atlas, particularly suggestions on how to improve it in the future. We are at

27 PART ONE The Geography of Health Care in the Middle Atlantic States

28 12 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES The Geography of Health Care in the Middle Atlantic States The use of health care resources in the Middle Atlantic States, like their use in the United States as a whole, is highly localized. Most Americans use the services of physicians whose practices are nearby. Physicians, in turn, are usually affiliated with hospitals that are near their practices. As a result, when patients are admitted to hospitals, the admission generally takes place within a relatively short distance of where the patient lives. Although the distances from homes to hospitals vary with geography people who live in rural areas travel farther than those who live in cities in general most patients are admitted to a hospital which provides an appropriate level of care close to where they live. The Medicare program maintains exhaustive records of hospitalizations, which makes it possible to define the patterns of use of hospital care. When Medicare enrollees are admitted to hospitals, the program s records identify both the patients places of residence (by ZIP Code) and the hospitals where the admissions took place (by a unique numerical identifier). These files provide a reliable basis for determining the geographic pattern of health care use, because research shows that the migration patterns of patients in the Medicare program are similar to those for younger patients. Medicare records of hospitalizations were used to define 3,436 geographically distinct hospital service areas in the United States. In each hospital service area, most of the care received by Medicare patients is provided by hospitals within the area. There are 326 of these hospital service areas in the Middle Atlantic States. The maps in this section show the location of each of these areas. Hospital service areas have been further aggregated into hospital referral regions, based on the pattern of use of cardiac surgery and neurosurgery. The maps also show the hospital referral regions to which the hospital service areas belong. A detailed description of how hospital service areas and hospital referral regions were defined, and of the methodologies used to create the Atlas of Health Care in the

29 THE GEOGRAPHY OF HEALTH CARE IN THE MIDDLE ATLANTIC STATES 13 Middle Atlantic States, is included in Part Nine of the national volume of the Dartmouth Atlas of Health Care. Population size in the hospital service areas in the Middle Atlantic States is given in Tables 2 and 4. The numbers of Medicare enrollees in each hospital service area are given in Tables 3 and 5.

30 14 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Hospital Service Areas Assigned to the Buffalo, NY Hospital Referral Region See Inset

31 THE GEOGRAPHY OF HEALTH CARE IN THE MIDDLE ATLANTIC STATES 15 Hospital Service Areas Assigned to the Rochester, NY Hospital Referral Region

32 16 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Hospital Service Areas Assigned to the Syracuse, NY Hospital Referral Region

33 THE GEOGRAPHY OF HEALTH CARE IN THE MIDDLE ATLANTIC STATES 17 Hospital Service Areas Assigned to the Binghamton and Elmira, NY Hospital Referral Regions

34 18 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Hospital Service Areas Assigned to the Albany, NY Hospital Referral Region

35 THE GEOGRAPHY OF HEALTH CARE IN THE MIDDLE ATLANTIC STATES 19 Hospital Service Areas Assigned to the Ridgewood, NJ and White Plains, NY Hospital Referral Regions See Inset

36 20 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Hospital Service Areas Assigned to the Bridgeport, Hartford and New Haven, CT Hospital Referral Regions

37 THE GEOGRAPHY OF HEALTH CARE IN THE MIDDLE ATLANTIC STATES 21 Hospital Service Areas Assigned to the East Long Island, NY Hospital Referral Region See Inset

38 22 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Hospital Service Areas Assigned to the New York, NY Hospital Referral Region See Detail on Facing Page

39 THE GEOGRAPHY OF HEALTH CARE IN THE MIDDLE ATLANTIC STATES 23 Detail of Hospital Service Areas Assigned to the Bronx, NY Hospital Referral Region

40 24 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Hospital Service Areas Assigned to the Hackensack and Paterson, NJ Hospital Referral Regions

41 THE GEOGRAPHY OF HEALTH CARE IN THE MIDDLE ATLANTIC STATES 25 Hospital Service Areas Assigned to the Newark, NJ Hospital Referral Region

42 26 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Hospital Service Areas Assigned to the Morristown, NJ Hospital Referral Region

43 THE GEOGRAPHY OF HEALTH CARE IN THE MIDDLE ATLANTIC STATES 27 Hospital Service Areas Assigned to the New Brunswick, NJ Hospital Referral Region

44 28 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Hospital Service Areas Assigned to the Camden, NJ Hospital Referral Region

45 THE GEOGRAPHY OF HEALTH CARE IN THE MIDDLE ATLANTIC STATES 29 Hospital Service Areas Assigned to the Wilmington, DE Hospital Referral Region

46 30 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Hospital Service Areas Assigned to the Philadelphia, PA Hospital Referral Region See Inset

47 THE GEOGRAPHY OF HEALTH CARE IN THE MIDDLE ATLANTIC STATES 31 Hospital Service Areas Assigned to the Lancaster and Reading, PA Hospital Referral Regions

48 32 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Hospital Service Areas Assigned to the Allentown, PA Hospital Referral Region

49 THE GEOGRAPHY OF HEALTH CARE IN THE MIDDLE ATLANTIC STATES 33 Hospital Service Areas Assigned to the Scranton and Wilkes-Barre, PA Hospital Referral Regions

50 34 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Hospital Service Areas Assigned to the Danville and Sayre, PA Hospital Referral Regions

51 THE GEOGRAPHY OF HEALTH CARE IN THE MIDDLE ATLANTIC STATES 35 Hospital Service Areas Assigned to the Harrisburg and York, PA Hospital Referral Regions

52 36 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Hospital Service Areas Assigned to the Altoona and Johnstown, PA Hospital Referral Regions

53 THE GEOGRAPHY OF HEALTH CARE IN THE MIDDLE ATLANTIC STATES 37 Hospital Service Areas Assigned to the Pittsburgh, PA Hospital Referral Region See Detail on Following Page

54 38 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Detail of Hospital Service Areas Assigned to the Pittsburgh, PA Hospital Referral Region

55 THE GEOGRAPHY OF HEALTH CARE IN THE MIDDLE ATLANTIC STATES 39 Hospital Service Areas Assigned to the Erie, PA Hospital Referral Region

56

57 PART TWO Acute Care Hospital Resources and Expenditures in the Middle Atlantic States This section provides measures of the allocation of hospital resources to the populations living in hospital service areas in the Middle Atlantic States. Data from the American Hospital Association and the Medicare program were used to estimate the numbers of staffed hospital beds, full time equivalent hospital employees, registered nurses employed in acute care hospitals, and hospital expenditures allocated to care for the population of each region. The population count is from the 1990 United States census. The estimates for resource allocations presented in the Atlas have been adjusted for differences in age and sex, and in the case of expenditures, for regional differences in prices. The allocation method adjusts for patient migration to hospitals located outside of the hospital service area where the patient resides. Part Nine of the national volume of the Dartmouth Atlas of Health Care explains how these adjustments were made.

58 42 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Acute Care Hospital Beds The number of acute care hospital beds per thousand residents varied substantially among the Middle Atlantic States, with bed supplies both higher and lower than the national average of 3.3 beds per thousand residents in all three states. The numbers of hospital beds allocated to local populations varied from fewer than 2.5 to more than 6.5. Among the region s larger hospital service areas, some were above the national average, including Newark, New Jersey (6.6); Manhattan (5.3); Trenton, New Jersey (4.6); Philadelphia (4.5); Pittsburgh (4.0); Buffalo, New York (3.8); and Camden, New Jersey (3.5). Some hospital service areas in the same states had fewer than the national average number of beds, including New Brunswick, New Jersey (3.1); Albany, New York (2.9); Allentown, Pennsylvania (2.9); Rochester, New York (2.9); and Syracuse, New York (2.7). Hospital Beds per 1,000 Residents in HSAs The Middle Atlantic States. The gray horizontal line represents the United States average. Figure 2.1. Acute Care Hospital Beds Allocated to Hospital Service Areas in the Middle Atlantic States (1993) The number of acute care hospital beds per thousand residents, after adjusting for differences in the age and sex of the local population, varied by a factor of more than 3.2. Each point represents one hospital service area.

59 ACUTE CARE HOSPITAL RESOURCES AND EXPENDITURES 43

60 44 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Acute Care Hospital Employees The number of full time equivalent hospital employees per thousand residents, like the number of hospital beds, varied substantially among the Middle Atlantic states. Among the region s larger hospital service areas, the numbers of hospital employees were more than twice the national average of 14.2 per thousand residents in Newark, New Jersey (29.0); and Manhattan (26.6); the numbers of employees were also high in Philadelphia (21.6); Pittsburgh (19.5); Trenton, New Jersey (18.4); and Buffalo, New York (18.2). Allentown, Pennsylvania (13.5) and Albany, New York (13.2) were below the national average. Hospital Employees per 1,000 Residents in HSAs The Middle Atlantic States. The gray horizontal line represents the United States average. Figure 2.2. Hospital Employees Allocated to Hospital Service Areas in the Middle Atlantic States (1993) The number of full time equivalent hospital employees per thousand residents, after adjusting for differences in the age and sex of the local population, varied by a factor of more than 2.8. Each point represents one hospital service area.

61 ACUTE CARE HOSPITAL RESOURCES AND EXPENDITURES 45

62 46 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Registered Nurses Employed in Acute Care Hospitals The acute care hospital-employed registered nurse workforce per thousand residents varied substantially among the Middle Atlantic states. Among the region s larger hospital service areas, the numbers of hospital-employed registered nurses were higher than the national average of 3.5 per thousand residents in Newark, New Jersey (6.8); Manhattan (5.7); Philadelphia (5.5); Pittsburgh, Pennsylvania (5.0); Trenton, New Jersey (4.5); Camden, New Jersey (4.4); and Buffalo, New York (4.2). Rochester, New York (3.5) and Syracuse, New York (3.4) were near the national average; and Albany, New York (3.2), was below it. Registered Nurses per 1,000 Residents in HSAs The Middle Atlantic States. The gray horizontal line represents the United States average. Figure 2.3. Hospital-Based Registered Nurses Allocated to Hospital Service Areas in the Middle Atlantic States (1993) The acute care hospital-employed registered nurse workforce per thousand residents, after adjusting for differences in the age and sex of the local population, varied by a factor of more than 3.0. Each point represents one hospital service area.

63 ACUTE CARE HOSPITAL RESOURCES AND EXPENDITURES 47

64 48 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Total Acute Care Hospital Expenditures Price adjusted per capita expenditures for inpatient and outpatient care delivered by acute care hospitals in the Middle Atlantic States varied by as much or more than other measures. Among the region s larger hospital service areas, the per capita expenditures were higher than the national average of $1,052 per capita in Newark, New Jersey ($1,924); Manhattan ($1,828); Philadelphia ($1,648); and Pittsburgh ($1,540). Camden, New Jersey ($1,152); Trenton, New Jersey ($1,123); and Buffalo, New York ($1,106) were near the national average; Rochester, New York ($975); New Brunswick, New Jersey ($949); Allentown, Pennsylvania ($926); Syracuse, New York ($900); and Albany, New York ($886) were below it. Total Hospital Expenditures per capita in HSAs (dollars) The Middle Atlantic States. The gray horizontal line represents the United States average. Figure 2.4. Price Adjusted Acute Care Hospital Expenditures Allocated to Hospital Service Areas in the Middle Atlantic States(1993) Price adjusted per capita expenditures for inpatient and outpatient care delivered by acute care hospitals varied by a factor of more than 3.7. Each point represents one hospital service area.

65 ACUTE CARE HOSPITAL RESOURCES AND EXPENDITURES 49

66 50 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Benchmarking: Acute Care Hospital Beds Figure 2.5. Acute Care Hospital Beds Allocated to Selected Hospital Service Areas in the Middle Atlantic States Compared to the Highest and Lowest Ranked Selected Areas (1993) The figure gives the ratio of acute care hospital beds in selected hospital service areas to the lowest and the highest ranked areas. It also compares each selected area to the U.S. average. The number of acute care hospital beds above (+) or below (-) the number predicted by the experience in the benchmark area for 1993 is in parentheses. For example, the number of beds per 1,000 allocated to the residents of Newark, New Jersey was 2.48 times higher than the number allocated to residents of Syracuse, New York. If the level of bed supply of the Syracuse benchmark in 1993 had been attained for the residents of Newark, 1,254 fewer beds would have been needed for Newark residents.

67 ACUTE CARE HOSPITAL RESOURCES AND EXPENDITURES 51 Benchmarking: Acute Care Hospital Beds Figure 2.6. Acute Care Hospital Beds Allocated to Selected Hospital Service Areas in the Middle Atlantic States Compared to Selected Hospital Service Areas Elsewhere in the U.S. (1993) The figure gives the ratio of acute care hospital beds in selected hospital service areas in the Middle Atlantic States to other areas. The number of beds above (+) or below (-) the number of beds predicted by the experience in the benchmark area is in parentheses. For example, the number of beds per 1,000 allocated to the residents of Newark, New Jersey, was 2.74 times higher than the number allocated to residents of Minneapolis. If the level of bed supply of the Minneapolis benchmark in 1993 had been attained for the residents of Newark, 1,333 fewer beds would have been needed for Newark residents. If the Boston benchmark had applied, 920 fewer beds would have been needed.

68 52 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Benchmarking: Hospital Employees Figure 2.7 Hospital Employees Allocated to Selected Hospital Service Areas in the Middle Atlantic States Compared to the Highest and Lowest Ranked Selected Areas (1993) The figure gives the ratio of full time equivalent hospital employees in selected hospital service areas to the lowest and the highest ranked areas. It also compares each selected area to the U.S. average. The number of employees above (+) or below (-) the number predicted by the experience in the benchmark area for 1993 is in parentheses. For example, the number of employees per 1,000 allocated to the residents of Newark, New Jersey, was 2.20 times higher than the number allocated to residents of Albany, New York. If the level of employment of the Albany benchmark in 1993 had been attained for the residents of Newark, 5,022 fewer employees would have been needed by residents of Newark.

69 ACUTE CARE HOSPITAL RESOURCES AND EXPENDITURES 53 Benchmarking: Hospital Employees Figure 2.8. Employees Allocated to Selected Hospital Service Areas in the Middle Atlantic States Compared to Selected Hospital Service Areas Elsewhere in the U.S. (1993) The figure gives the ratio of full time equivalent hospital employees in selected hospital service areas in the Middle Atlantic States to other areas. The number of employees above (+) or below (-) the number of employees predicted by the experience in the benchmark area is in parentheses. For example, the number of employees per 1,000 allocated to the residents of Newark, New Jersey was 2.62 higher than the number allocated to residents of Minneapolis. If the level of employment of the Minneapolis benchmark in 1993 had been attained for the residents of Newark, 5,682 fewer employees would have been needed. If the Boston benchmark had applied, 1,279 fewer employees would have been needed by Newark residents.

70 54 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Benchmarking: Hospital-Based Registered Nurses Figure 2.9. Hospital-Based Registered Nurses Allocated to Selected Hospital Service Areas in the Middle Atlantic States Compared to Highest and Lowest Ranked Selected Areas (1993) The figure gives the ratio of hospital-employed registered nurses in selected hospital service areas to the lowest and the highest ranked areas. It also compares each selected area to the U.S. average. The number of registered nurses above (+) or below (-) the number predicted by the experience in the benchmark area for 1993 is in parentheses. For example, the number of registered nurses per 1,000 allocated to the residents of Newark, New Jersey was 2.13 times higher than the number allocated to Albany, New York. If the level of nursing employment of the Albany benchmark in 1993 had been attained for the residents of Newark, 1,154 fewer registered nurses would have been needed by Newark residents.

71 ACUTE CARE HOSPITAL RESOURCES AND EXPENDITURES 55 Benchmarking: Hospital-Based Registered Nurses Figure Hospital-Based Registered Nurses Allocated to Selected Hospital Service Areas in the Middle Atlantic States Compared to Selected Hospital Service Areas Elsewhere in the U.S. (1993) The figure gives the ratio of hospital-employed registered nurses in selected hospital service areas in the Middle Atlantic States to other areas. The number of registered nurses above (+) or below (-) the number of registered nurses predicted by the experience in the benchmark area is in parentheses. For example, the number of registered nurses per 1,000 allocated to the residents of Newark, New Jersey, was 2.45 higher than the number allocated to residents of Minneapolis. If the level of nursing employment of the Minneapolis benchmark in 1993 had been attained for the residents of Newark, 1,287 fewer registered nurses would have been needed by Newark residents. If the Boston benchmark had applied, 453 fewer registered nurses would have been needed.

72 56 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Benchmarking: Total Hospital Expenditures Figure 2.11 Price Adjusted Total Hospital Expenditure per capita in Selected Hospital Service Areas in the Middle Atlantic States Compared to Highest and Lowest Ranked Selected Areas (1993) The figure gives the ratio of price adjusted per capita expenditures for inpatient and outpatient care in selected hospital service areas to the lowest and the highest ranked areas. It also compares each selected area to the U.S. average. Per capita expenditures above (+) or below (-) the amount predicted by the experience in the benchmark area for 1993 are in parentheses. For example, expenditures in Newark, New Jersey, were 2.17 times higher than in Albany, New York. If the level of expenditure of the Albany benchmark in 1993 had been attained for the residents of Newark, $329.3 million less would have been spent for Newark residents.

73 ACUTE CARE HOSPITAL RESOURCES AND EXPENDITURES 57 Benchmarking: Total Hospital Expenditures Figure 2.12 Price Adjusted Total Hospital Expenditures per capita in Selected Hospital Services Areas in the Middle Atlantic States Compared to Selected Hospital Service Areas Elsewhere in the U.S. (1993) The figure gives the ratio of price adjusted per capita expenditures for inpatient and outpatient care in selected hospital service areas in the Middle Atlantic States to other areas. Per capita expenditures above (+) or below (-) the amount predicted by the experience in the benchmark area is in parentheses. For example, expenditures in Newark, New Jersey, were 2.08 higher than in Minneapolis. If the level of expenditure of the Minneapolis benchmark in 1993 had been attained for the residents of Newark, $317.4 million less would have been spent. If the Boston benchmark had applied, $11 million fewer dollars would have been spent for Newark residents.

74 58 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES TABLE 2 Health care services utilization is expressed in rates per thousand residents. Rates are adjusted for differences in age, sex, and race composition of areas populations. The rates represent the health care utilization of persons living in the specified area, regardless of where services were obtained. Reimbursements are expressed in rates per person, and are adjusted for regional differences in prices. Estimates of allocated hospital employees and registered nurses are expressed as full-time equivalents (FTEs). See Part Nine of the national volume of the Dartmouth Atlas of Health Care for details.

75 ACUTE CARE HOSPITAL RESOURCES AND EXPENDITURES 59 TABLE 2 Acute Care Hospital Resources Allocated to Hospital Service Areas Hospital Service Area Resident Population Acute Care Beds per 1000 Hospital Employees per 1000 Hospital-based Registered Nurses per 1000 Price-Adjusted Expenditures per capita Hospital Service Area Resident Population Acute Care Beds per 1000 Hospital Employees per 1000 Hospital-based Registered Nurses per 1000 Price-Adjusted Expenditures per capita New Jersey Atlantic City 154, ,115 Bayonne 61, ,114 Belleville 61, Bridgeton 87, ,003 Camden 509, ,152 Cape May Court House 70, ,096 Denville 104, ,028 Dover 139, Edison 175, Elizabeth 189, ,099 Elmer 36, Englewood 133, Flemington 96, Freehold 98, Hackensack 137, Hackettstown 40, Hammonton 23, ,222 Hoboken 103, Holmdel 111, Irvington 60, ,120 Jersey City 228, ,407 Kearny 64, Lakewood 125, Livingston 107, ,074 Long Branch 78, ,292 Manahawkin 57, Montclair 150, Morristown 155, Mount Holly 161, ,164 Neptune 116, ,114 New Brunswick 282, Newark 317, ,924 Newton 72, North Bergen 95, Orange 61, ,340 Paramus 25, ,474 Passaic 211, Paterson 168, ,091 Perth Amboy 46, ,110 Phillipsburg 66, Plainfield 126, Point Pleasant 107, Pompton Plains 105, Princeton 146, Rahway 74, Red Bank 114, Ridgewood 187, Riverside 48, ,052 Salem 50, ,251 Secaucus 14, ,325 Somers Point 62, ,129 Somerville 131, South Amboy 56, Stratford 161, Summit 152, Sussex 44, Teaneck 144, Toms River 181, Trenton 277, ,123 Union 89, ,052 Vineland 64, ,099 Wayne 89, Westwood 100, Willingboro 81, ,164 Woodbury 119, New York Albany 301, Alexandria Bay 9, Amityville 119, Amsterdam 56, ,158 Auburn 80, Batavia 67, Bath 23, Bay Shore 173, Bethpage 130, Binghamton 263, Brockport 38,

76 60 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Hospital Service Area Resident Population Acute Care Beds per 1000 Hospital Employees per 1000 Hospital-based Registered Nurses per 1000 Price-Adjusted Expenditures per capita Hospital Service Area Resident Population Acute Care Beds per 1000 Hospital Employees per 1000 Hospital-based Registered Nurses per 1000 Price-Adjusted Expenditures per capita Bronx 1,118, ,760 Bronxville 63, Brooklyn 2,184, ,266 Buffalo 796, ,106 Callicoon 3, Cambridge 15, Canandaigua 59, Carmel 72, Carthage 14, ,040 Catskill 63, Clifton Springs 25, Cobleskill 23, Cold Spring 4, Cooperstown 37, ,485 Corning 44, Cornwall 63, Cortland 59, Cuba 9, Dansville 36, Dobbs Ferry 15, Dunkirk 39, East Meadow 105, ,445 Elizabethtown 6, Ellenville 11, Elmira 99, ,043 Far Rockaway 134, ,418 Flushing 855, ,120 Fulton 32, Geneva 48, Glen Cove 72, Glens Falls 129, Gloversville 46, Goshen 62, Gouverneur 11, ,112 Gowanda 18, Greenport 16, Hamilton 27, Harris 50, ,534 Hornell 26, ,223 Huntington 188, Irving 22, Ithaca 94, Jamaica 637, ,113 Jamestown 82, Kenmore 96, Kingston 123, Lackawanna 35, Lewiston 57, Little Falls 21, Lockport 54, Long Beach 50, Long Island City 142, Lowville 20, ,102 Malone 31, ,034 Manhasset 166, Margaretville 9, ,018 Massena 18, ,230 Medina 33, Middletown 90, Mineola 177, ,000 Montour Falls 12, ,274 Mount Kisco 125, Mount Vernon 68, New Rochelle 92, New York 1,812, ,828 Newark 34, Newburgh 74, ,043 Newfane 14, Niagara Falls 47, ,079 North Tarrytown 84, North Tonawanda 51, Norwich 25, ,065 Nyack 163, Oceanside 181, Ogdensburg 30, Olean 64, Oneida 39, ,079 Oneonta 45, ,059 Oswego 45, Patchogue 180, Peekskill 64, Penn Yan 21, Plainview 71, Plattsburgh 93, Port Chester 78, Port Jefferson 205, Port Jervis 41, Potsdam 47, Poughkeepsie 223, Rhinebeck 20, Riverhead 45, Rochester 749, Rockville Centre 109, Rome 74,

77 ACUTE CARE HOSPITAL RESOURCES AND EXPENDITURES 61 Hospital Service Area Resident Population Acute Care Beds per 1000 Hospital Employees per 1000 Hospital-based Registered Nurses per 1000 Price-Adjusted Expenditures per capita Hospital Service Area Resident Population Acute Care Beds per 1000 Hospital Employees per 1000 Hospital-based Registered Nurses per 1000 Price-Adjusted Expenditures per capita Saranac Lake 28, ,004 Saratoga Springs 74, Schenectady 222, Seaford 21, Sidney 21, ,004 Smithtown 193, Sodus 25, Southampton 50, Springville 27, Star Lake 4, ,301 Staten Island 378, ,077 Stony Brook 29, Suffern 104, Syosset 42, Syracuse 529, Ticonderoga 11, ,237 Troy 162, Utica 211, Valley Stream 139, Walton 8, ,216 Warsaw 29, ,202 Warwick 24, Watertown 94, Wellsville 30, West Islip 193, Westfield 13, White Plains 136, ,042 Yonkers 155, Pennsylvania Abington 121, ,023 Aliquippa 39, ,312 Allentown 309, Altoona 122, ,150 Ashland 11, ,266 Beaver 112, ,097 Berwick 31, ,291 Bethlehem 131, Bloomsburg 39, Braddock 18, ,299 Bradford 31, ,157 Bristol 49, ,146 Brookville 23, ,258 Brownsville 22, ,204 Bryn Mawr 124, Butler 76, ,031 Camp Hill 146, Canonsburg 35, Carbondale 26, Carlisle 84, Chambersburg 95, Clarion 32, ,150 Clearfield 42, ,315 Coaldale 25, ,304 Coatesville 62, Connellsville 33, ,032 Corry 19, ,254 Coudersport 17, ,123 Danville 43, ,534 Darby 96, ,235 Doylestown 87, Drexel Hill 118, Dubois 43, ,164 East Stroudsburg 94, Easton 113, Ellwood City 25, ,104 Ephrata 53, Erie 261, ,088 Everett 33, Franklin 57, ,228 Gettysburg 46, Greensburg 79, ,345 Greenville 47, ,153 Grove City 33, Hanover 62, Harrisburg 242, ,150 Hazleton 75, ,028 Hershey 20, ,294 Honesdale 32, Huntingdon 45, Indiana 64, ,167 Jeannette 77, ,049 Jersey Shore 16, Johnstown 151, ,518 Kane 10, ,200 Kingston 36, ,068 Kittanning 44, ,108 Lancaster 372, Langhorne 237, Lansdale 80, Latrobe 75, ,106 Lebanon 119, Lehighton 27, Lewisburg 72, Lewistown 66, ,010

78 62 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Hospital Service Area Resident Population Acute Care Beds per 1000 Hospital Employees per 1000 Hospital-based Registered Nurses per 1000 Price-Adjusted Expenditures per capita Hospital Service Area Resident Population Acute Care Beds per 1000 Hospital Employees per 1000 Hospital-based Registered Nurses per 1000 Price-Adjusted Expenditures per capita Lock Haven 32, ,257 Mcconnellsburg 13, ,022 Mckees Rocks 25, ,371 Mckeesport 79, ,216 Meadville 66, ,034 Media 50, ,065 Meyersdale 10, Monongahela 68, ,227 Monroeville 96, ,214 Montrose 8, ,059 Mount Pleasant 42, ,233 Muncy 27, Natrona Heights 92, ,005 New Castle 80, ,337 New Kensington 41, ,069 Norristown 179, Palmerton 17, Paoli 49, Peckville 6, Philadelphia 1,783, ,648 Philipsburg 14, Phoenixville 59, Pittsburgh 1,120, ,540 Pottstown 81, Pottsville 117, ,039 Punxsutawney 21, ,204 Quakertown 35, Reading 300, Renovo 3, ,500 Ridgway 10, ,416 Ridley Park 94, ,046 Roaring Spring 23, Sayre 63, Scranton 222, ,056 Sellersville 89, Sewickley 79, ,193 Shamokin 21, ,557 Sharon 53, ,419 Somerset 39, ,334 Spangler 24, ,198 St Marys 25, ,040 State College 110, Sunbury 48, ,113 Susquehanna 12, ,184 Titusville 24, ,259 Towanda 20, Tunkhannock 22, Tyrone 17, ,039 Union City 8, Uniontown 82, ,190 Upland 116, ,396 Warminster 37, Warren 38, Washington 87, ,070 Waynesboro 45, Waynesburg 32, ,480 Wellsboro 39, West Chester 141, West Grove 41, Wilkes-Barre 221, Williamsport 88, Windber 16, ,240 York 278,

79 PART THREE The Medicare Program in the Middle Atlantic States

80 64 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES The Medicare Program in the Middle Atlantic States Most Americans over the age of 65 receive their medical care from traditional Medicare. That is, their care is obtained from providers who charge on a fee-forservice basis, either as independent practitioners or as members of health maintenance organizations that are not capitated. In , over 95% of Medicare outlays for people over 65 were reimbursed on a fee-for-service basis. There were large differences in these reimbursements between hospital service areas in the Middle Atlantic States: total program outlays varied by a factor of more than 2; reimbursements for professional and laboratory services by a factor of more than 1.9; and reimbursements for outpatient services by a factor of more than 4.2. Many policy experts have recommended greater enrollment in capitated managed care among the Medicare population as a means of both cost containment and improvement in the quality of care. The inequalities between areas in capitation payments, however, raise a serious challenge to implementing this strategy. The basis for the federal capitation payment for managed care coverage of Medicare enrollees is the Average Adjusted Per Capita Cost, or AAPCC. The amount is determined by the fee-for-service payments in the enrollee s county of residence. Since there are large differences in reimbursements among hospital service areas, the amount reimbursed varies strikingly from one region to another. These disparities have stimulated a growing debate about geographic equity. Most of the attention has focused on the differences between states or large sections of the country. For example, the AAPCC in 1996 for residents of the Minneapolis hospital service area was $4,599. Residents of the Miami hospital service area received $8,245, which is almost 80% higher. Yet because the federal contribution is based on historical reimbursements within the county where the enrollee lives, there are also striking variations within states. In 1996, the AAPCC in New York varied by a factor of more than 2.5, from $4,398 in Syracuse and $4,562 in Albany to $8,542 in Manhattan.

81 THE MEDICARE PROGRAM 65 The differences in the AAPPC payment may reflect differences in prices that exist between regions. To remove price as a factor in explaining the differences, the AAPCC has been price adjusted, according to the method described in Part Nine of the national volume of The Dartmouth Atlas of Health Care. These adjustments, in some cases, make a substantial difference. The benchmarks for the AAPCC in Part Three include adjusted as well as unadjusted rates. Note on Methods Estimates for reimbursements are based on a 5% sample of the Medicare population as recorded in the Continuous Medicare History File. The data are for , and the rates are an annualized average for the two year period. Fee-for-service reimbursements have been price adjusted to take into account differences in the cost of living among hospital service areas. A description of the methods used to make these price adjustments is in Part Nine of the national volume of The Dartmouth Atlas of Health Care. The estimates for the AAPCC in each hospital service area have been made as follows. When a hospital service area was located entirely within the boundaries of a county, the AAPCC is for that county. When a hospital service area overlaps two or more counties, the estimate is a weighted average, based on the proportion of the hospital service area s Medicare enrollees who resided in each county in Price adjustments to the AAPCC were made according to the method described in Part Nine of the national volume of The Dartmouth Atlas of Health Care. The population used to estimate the dollars above or below the amount predicted by the benchmark (Figures ) is the 1993 enrollee population. The estimates therefore do not include population gain or loss that may have occurred since 1993.

82 66 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Medicare Reimbursements for Traditional (Noncapitated) Medicare Per enrollee reimbursements by the Medicare program for all services varied widely among and within the Middle Atlantic States. Among the region s larger hospital service areas, per enrollee reimbursements were above the national average of $3,650 in Pittsburgh ($4,854); Philadelphia ($4,473); Newark, New Jersey ($4,317); Allentown, Pennsylvania ($4,235); Manhattan ($4,003); and Camden, New Jersey ($3,892). Trenton, New Jersey ($3,721); and New Brunswick, New Jersey ($3,217) were near the national average; Syracuse, New York ($3,050); Rochester, New York ($3,047); Buffalo, New York ($2,963); and Albany, New York ($2,771) were below it. Price Adjusted Reimbursements for All Services per Medicare Enrollee in HSAs (dollars) The Middle Atlantic States. The gray horizontal line represents the United States average. Figure 3.1. Price Adjusted Reimbursements for Traditional (Noncapitated) Medicare in Hospital Service Areas in the Middle Atlantic States ( ) Per enrollee reimbursements by the Medicare program for all services varied by a factor of more than 2. Each point represents one hospital service area.

83 THE MEDICARE PROGRAM 67

84 68 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Medicare Reimbursements for Professional and Laboratory Services Reimbursements for professional and laboratory services varied substantially among the Middle Atlantic States. Among the region s larger hospital service areas, per enrollee reimbursements for professional and laboratory services were above the national average of $975 in Philadelphia ($1,336); Pittsburgh ($1,271); Allentown, Pennsylvania ($1,233); Newark, New Jersey ($1,169); Manhattan ($1,150); and Camden, New Jersey ($1,140). New Brunswick, New Jersey ($947); Syracuse, New York ($918); Albany, New York ($875); Buffalo, New York ($862); and Rochester, New York ($741) were all below the national average. Price Adjusted Reimbursements for Professional and Lab Services per Medicare Enrollee in HSAs The Middle Atlantic States. The gray horizontal line represents the United States average. Figure 3.2. Price Adjusted Part B Medicare Reimbursements for Professional and Laboratory Services In Hospital Service Areas in the Middle Atlantic States ( ) Reimbursements for professional and laboratory services varied by a factor of more than 2.9. Each point represents one hospital service area.

85 THE MEDICARE PROGRAM 69

86 70 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Medicare Reimbursements for Inpatient Hospital Services Per enrollee Medicare reimbursements for inpatient acute care hospital services varied substantially among the Middle Atlantic States. Among the region s larger hospital service areas, per enrollee reimbursements for inpatient acute care hospital services were higher than the national average of $1,852 in Philadelphia ($2,393); Newark, New Jersey ($2,368); Pittsburgh ($2,257); Manhattan ($2,228); Trenton, New Jersey ($2,211); and Camden, New Jersey ($2,144). Inpatient reimbursements were lower than the national average in the hospital service areas in Rochester, New York ($1,689); Syracuse, New York ($1,626); Buffalo, New York ($1,612); and Albany, New York ($1,399). Price Adjusted Reimbursements for Inpatient Hospital Services per Medicare Enrollee in HSAs (dollars) The Middle Atlantic States. The gray horizontal line represents the United States average. Figure 3.3. Price Adjusted Medicare Reimbursements for Inpatient Hospital Services per Medicare Enrollee in Hospital Service Areas in the Middle Atlantic States ( ) Per enrollee Medicare reimbursements for inpatient acute care hospital services varied by a factor of more than 2.2. Each point represents one hospital service area.

87 THE MEDICARE PROGRAM 71

88 72 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Medicare Reimbursements for Outpatient Services Price adjusted Medicare reimbursements for outpatient services varied substantially among and within the Middle Atlantic States. Hospital service areas in New York tended to be lower than the national average of $319 per Medicare enrollee, while New Jersey and Pennsylvania had a number of areas that were above it. Among the region s larger hospital service areas, per enrollee reimbursements for outpatient acute care hospital services were higher than the national average in Pittsburgh ($372); Trenton, New Jersey ($372); Newark, New Jersey ($345); and Philadelphia ($325). Allentown, Pennsylvania ($285); Rochester, New York ($262); Manhattan ($261); Camden, New Jersey ($229); Syracuse, New York ($226); Buffalo, New York ($222); Albany, New York ($209); and New Brunswick, New Jersey ($195) were below the national average. Price Adjusted Reimbursements for Outpatient Services per Medicare Enrollee in HSAs (dollars) The Middle Atlantic States. The gray horizontal line represents the United States average. Figure 3.4. Price Adjusted Medicare Reimbursements for Outpatient Services In Hospital Service Areas in the Middle Atlantic States ( ) Price adjusted Medicare reimbursements for outpatient services varied by a factor of more than 4.2. Each point represents one hospital service area.

89 THE MEDICARE PROGRAM 73

90 74 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Average Adjusted Per Capita Costs The Adjusted Average per Capita Cost varied substantially among the Middle Atlantic States, particularly in New York and Pennsylvania. The majority of hospital service areas in New Jersey were above the national average. Among the region s larger hospital service areas, the AAPCC was well above the national average of $5,291 in Manhattan ($8,542); Philadelphia ($7,855); Pittsburgh ($6,657); Trenton, New Jersey ($6,265); Newark, New Jersey ($6,217); and Camden, New Jersey ($6,181). Hospital service areas with AAPCCs below the national average included Rochester, New York ($4,932); Buffalo, New York ($4,717); Albany, New York ($4,562); and Syracuse, New York ($4,398). AAPCC for 1996 in HSAs The Middle Atlantic States. The gray horizontal line represents the United States average. Figure 3.5. The Adjusted Average per Capita Cost in Hospital Service Areas in the Middle Atlantic States (1996) The AAPCC in the Middle Atlantic States varied by a factor of more than 2.1. Each point represents one hospital service area.

91 THE MEDICARE PROGRAM 75

92 76 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Medicare Enrollment in Capitated Managed Care Plans Since the early 1970s, Medicare beneficiaries have been offered the option of joining risk bearing, or capitated, health maintenance organizations. Under the capitation plan, the federal government pays health maintenance organizations a fixed annual amount per enrollee. In exchange, the health maintenance organization must provide all required services. If the total costs of care exceed the amount the government pays, then the health maintenance organization must absorb the loss; if they are less, then the health maintenance organization may retain the difference. In 1993, about 1.6 million, or 5.2%, of all Medicare enrollees were covered by riskbearing health maintenance organizations, but enrollment was geographically very uneven across the United States. Enrollment of Medicare beneficiaries in the Middle Atlantic States was also highly variable. More than 15% of Medicare enrollees in Rochester, New York, about 9.5% of the Medicare population of Staten Island, New York, and 9.3% in Abington, Pennsylvania were enrolled in health maintenance organizations. But in most areas of the Middle Atlantic States, less than 5.0 % of the Medicare population were in risk-bearing health maintenance organizations; among towns in Western Pennsylvania, including Erie, Johnstown, and Grove City, the proportion was 0.02% or less.

93 THE MEDICARE PROGRAM 77

94 78 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES The Boundaries of Counties, Hospital Service Areas, and the AAPCC As natural markets, hospital service areas commonly cross city limits and county boundaries, and sometimes even state lines. Some hospital service areas have component ZIP Codes in several different counties, and others are contained wholly within one county. Since the AAPCC is calculated on the basis of county-level utilization experience, its value represents the weighted average of the costs of variable numbers of health care markets. For counties containing several hospital service areas, the AAPCC s value may not be closely related to the actual costs of providing care in a given area. For example, in New York, the hospital service areas of Huntington, Southampton and Smithtown are all in Suffolk County, and therefore they have the same AAPCC. Yet Medicare reimbursements in these markets are quite different: in , they were $3,342 for Medicare enrollees living in Huntington, $3,770 for enrollees in Southampton, and $4,489 for those in Smithtown. Since the actual cost of care for residents in Huntington is below the value of the AAPCC, managed care organizations might have a strong incentive to target this community, thus increasing Medicare reimbursements there toward the county average. If health maintenance organizations avoided communities like Smithtown (where costs exceed the AAPCC), the net effect would be an accelerated increase in overall Medicare costs. Map 3.7 shows the boundaries of Suffolk County, New York and its constituent hospital service areas. Note that some hospital service areas cross county lines, so the AAPCC for these hospital service areas is a weighted average of the AAPCC for the constituent counties.

95 THE MEDICARE PROGRAM 79 County and Hospital Service Area Boundaries, Suffolk County, New York

96 80 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Benchmarking: Total Medicare Reimbursements Figure 3.6 Price Adjusted Total Reimbursements per Medicare Enrollee in Selected Hospital Service Areas in the Middle Atlantic States Compared to Highest and Lowest Selected Areas ( ) The figure gives the ratios of total Medicare reimbursements per enrollee in selected areas to the highest and lowest ranked areas. It also compares each area to the U.S. average. The number of dollars above (+) or below (-) the level of expenditures predicted by the experience in the benchmark areas for are in parentheses. For example, price adjusted total Medicare expenditures per enrollee in Pittsburgh were 1.75 times greater than in Albany, New York; if the expenditure pattern for Albany in had been attained in Pittsburgh, $772 million less would have been spent for Medicare enrollees in Pittsburgh.

97 THE MEDICARE PROGRAM 81 Benchmarking: Total Medicare Reimbursements Figure 3.7. Price Adjusted Total Reimbursements per Medicare Enrollee in Selected Hospital Services Areas in the Middle Atlantic States Compared to Selected Hospital Service Areas Elsewhere in the U.S. ( ) The figure gives the ratios of total reimbursements in selected hospital service areas in the Middle Atlantic States to other areas. The numbers of dollars above (+) or below (-) the level of reimbursements predicted by the experience in the benchmark areas are in parentheses. For example, price adjusted total reimbursements per Medicare enrollee in Pittsburgh were 1.63 times greater than in Minneapolis. If the level of expenditures in Minneapolis in had been attained in Pittsburgh, $695 million less would have been spent on Pittsburgh residents. If the level of reimbursements in Miami had been attained, $313 million more would have been spent in Pittsburgh.

98 82 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Benchmarking: Reimbursements for Professional and Laboratory Services Figure 3.8. Price Adjusted Total Reimbursements for Professional and Laboratory Services per Medicare Enrollee in Selected Hospital Services Areas in the Middle Atlantic States Compared to Highest and Lowest Ranked Areas ( ) The figure gives the ratios of reimbursements for professional and laboratory services in selected areas to the highest and lowest ranked areas. It also compares each area to the U.S. average. The numbers of dollars above (+) or below (-) the amount of reimbursements for professional and laboratory services predicted by the experience in the benchmark areas for are in parentheses. For example, price adjusted expenditures per enrollee in Philadelphia were 1.80 times greater than in Rochester, New York; if the level of expenditures in Rochester in had been attained in Philadelphia, $297 million less would have been spent for Philadelphia residents.

99 THE MEDICARE PROGRAM 83 Benchmarking: Reimbursements for Professional and Laboratory Services Figure 3.9. Price Adjusted Total Reimbursements for Professional and Laboratory Services per Medicare Enrollee in Selected Hospital Service Areas in the Middle Atlantic States Compared to the Selected Hospital Service Areas Elsewhere in the U.S. ( ) The figure gives the ratio of total reimbursements for professional and laboratory services per Medicare enrollee in selected areas to other areas. The dollars above (+) or below (-) the amount predicted by the experience in the benchmark area for are in parentheses. For example, price adjusted professional and laboratory expenditures per Medicare enrollee in Philadelphia were 2.46 times higher than in Minneapolis. If the expenditures in Minneapolis in had been attained in Philadelphia, $395 million less would have been spent on professional and laboratory services for Medicare residents of Philadelphia. If the level of reimbursements in Miami had been attained, $471 million more would have been spent in Philadelphia.

100 84 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Benchmarking: AAPCC Figure AAPCC in Selected Hospital Service Areas in the Middle Atlantic States Compared to the Highest and Lowest Ranked Selected Areas (1996). The AAPCC is Not Adjusted for Price Differences. The figure gives the ratio of the AAPCC in selected areas to the highest and lowest ranked areas. It also compares each area to the U.S. average. The numbers of dollars above (+) or below (-) the amount predicted by the experience in the benchmark areas for 1996 are in parentheses. For example, the AAPCC in Manhattan was 1.94 times greater than in Syracuse, New York; if the AAPCC in Syracuse in 1996 had been attained in Manhattan, $853 million less would have been spent for Manhattan residents.

101 THE MEDICARE PROGRAM 85 Benchmarking: AAPCC Figure Price Adjusted AAPCC in Selected Hospital Service Areas in the Middle Atlantic States Compared to Highest and Lowest Ranked Areas (1996) The figure gives the ratios of AAPCCs in selected areas to the highest and lowest ranked areas. It also compares each area to the U.S. average. The numbers of dollars above (+) or below (-) the amount of reimbursements for professional and laboratory services predicted by the experience in the benchmark areas for 1996 are in parentheses. For example, price adjusted expenditures per enrollee in Philadelphia were 1.60 times greater than in Syracuse, New York; if the level of expenditures in Syracuse in 1996 had been attained in Philadelphia, $665 million less would have been spent for residents of Philadelphia.

102 86 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Benchmarking: AAPCC Figure AAPCC in Selected Hospital Service Areas in the Middle Atlantic States Compared to Selected Hospital Service Areas Elsewhere in the U.S. (1996). The AAPCC is Not Adjusted for Price Differences. The figure gives the ratio of the AAPCC in selected areas to other areas. The dollars above (+) or below (-) the amount predicted by the experience in the benchmark area for 1996 are in parentheses. For example, the AAPCC in Manhattan was 1.86 times higher than in Minneapolis. If the expenditures in Minneapolis in 1996 had been attained in Manhattan, $812 million less would have been spent for Medicare residents of Manhattan. If the 1996 AAPCC in Miami had been attained, $61 million less would have been spent in Manhattan.

103 THE MEDICARE PROGRAM 87 Benchmarking: AAPCC Figure Price Adjusted AAPCC in Selected Hospital Service Areas in the Middle Atlantic States Compared to Selected Hospital Service Areas Elsewhere in the U.S. (1996) The figure gives the ratios of adjusted AAPCCs in selected areas to the highest and lowest ranked areas. It also compares each area to the U.S. average. The numbers of dollars above (+) or below (-) the amount of reimbursements for professional and laboratory services predicted by the experience in the benchmark areas for 1996 are in parentheses. For example, price adjusted expenditures per enrollee in Philadelphia were 1.61 times greater than in Minneapolis; if the level of expenditures in Minneapolis in 1996 had been attained in Philadelphia, $669 million less would have been spent for residents of Philadelphia.

104 88 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES TABLE 3 The data are age, sex and race adjusted for Medicare enrollees who were not members of risk bearing health maintenance organizations on June 30, See Part Nine, section 4, of the national volume of the Dartmouth Atlas of Health Care for details on constructing rates and making price adjustments. Data for three categories of expenditure total expenditures, physician and laboratory services, and outpatient services are based on a 5% sample of Medicare enrollees. To report average reimbursement rates in the figures and maps in Part Three with adequate statistical precision, we required that the sample size for a hospital service area (HSA) be large enough to ensure that the rate have a standard error of less than 10% of the national average. The minimum sample size varies according to category of expenditures, since a varying proportion of enrollees experience a claim, according to category. For total Medicare expenditures, the minimum sample size is 600 enrollees; since the estimate is based on a 5% sample, only HSAs with 12,000 enrollee person-years of experience are included in the figures and maps. For professional and laboratory services, the minimum is 6,720 person-years; for outpatient services it is 18,300. Rates for HSAs with less than the minimum population size are given in parentheses in Table 3. Rates for areas with fewer than 400 personyears (i.e., a sample of 10 or fewer) are omitted from the table. Inpatient reimbursements are based on a complete enumeration (100% sample) for the years We omitted all areas with total census population of 3,500 or fewer from the figures and maps. The data for areas that fall below this minimum appear in parentheses in Table 3. Data for HSAs with 10 or fewer counts are omitted from the table (the cell is blank). The AAPCC is the Average Adjusted per Capita Cost. The data for the AAPCC are based on published federal rates. For hospital service areas that cross county boundaries, the rates are weighted averages. Price adjustments to the AAPCC were made according to the method described in Part Nine of the national volume of the Dartmouth Atlas of Health Care.

105 THE MEDICARE PROGRAM 89 TABLE 3 Medicare Reimbursements per Enrollee by Program Components ( ) and Adjusted Average Per Capita Cost (1996) for Hospital Service Areas Hospital Service Area Resident Population Medicare Enrollees (1992 plus 1993) Price Adjusted Reimbursements for All Services Price Adjusted Reimbursements for Professional and Lab Services Price Adjusted Reimbursements for Inpatient Hospital Services Price Adjusted Reimbursements for Outpatient Facilities AAPCC (1996) New Jersey Atlantic City 154,316 39,038 3,508 1,147 2, ,960 5,380 Bayonne 61,444 21,514 3,973 1,188 2, ,064 5,109 Belleville 61,365 19,195 3,456 1,080 1, ,217 5,051 Bridgeton 87,961 22,633 3,965 1,101 2, ,723 5,571 Camden 509, ,471 3,892 1,140 2, ,181 5,641 Cape May Court House 70,984 28,537 4,812 1,410 2, ,968 5,387 Denville 104,485 20,986 3,422 1,027 1, ,506 4,473 Dover 139,426 22,673 3,619 1,037 2, ,468 4,442 Edison 175,032 43,733 3,279 1,056 1, ,990 4,884 Elizabeth 189,124 47,545 2, , ,797 4,710 Elmer 36,897 7,647 (3,820) 1,117 2,195 (246) 6,173 5,634 Englewood 133,340 41,884 2,869 1,030 1, ,562 4,513 Flemington 96,472 18,475 3, , ,376 4,383 Freehold 98,712 24,398 3,221 1,017 1, ,678 5,012 Hackensack 137,814 42,943 2, , ,562 4,513 Hackettstown 40,212 7,623 (3,599) 983 1,782 (307) 5,980 4,858 Hammonton 23,068 6,850 (3,867) 1,143 2,225 (233) 5,960 5,380 Hoboken 103,043 19,358 3,844 1,075 1, ,064 5,109 Holmdel 111,073 22,730 3,758 1,103 2, ,692 5,025 Irvington 60,986 9,590 (3,781) 1,096 2,190 (190) 6,217 5,051 Jersey City 228,537 42,100 3, , ,064 5,109 Kearny 64,085 18,214 3, ,905 (171) 5,905 4,976 Lakewood 125,880 43,266 3,726 1,157 1, ,299 4,678 Livingston 107,839 33,712 3,205 1,029 1, ,217 5,051 Long Branch 78,311 21,051 3,695 1,092 2, ,692 5,025 Manahawkin 57,947 23,190 3, , ,260 4,643 Montclair 150,696 47,015 3,243 1,062 1, ,217 5,051 Morristown 155,945 39,693 3, , ,395 4,383 Mount Holly 161,533 33,716 3, , ,804 5,297 Neptune 116,432 34,317 3,479 1,070 1, ,692 5,025 New Brunswick 282,900 54,119 3, , ,837 4,759 Newark 317,309 52,423 4,317 1,169 2, ,217 5,051 Newton 72,874 15,883 3,441 1,076 1,619 (313) 5,318 4,321 North Bergen 95,558 23,610 3,502 1,134 1, ,064 5,109 Orange 61,407 12,216 3,521 1,160 1,990 (251) 6,217 5,051 Paramus 25,085 8,517 (3,793) 1,080 1,871 (289) 5,562 4,513 Passaic 211,422 67,244 2, , ,519 4,479 Paterson 168,959 33,481 3,364 1,056 1, ,503 4,466 Price-Adjusted AAPCC (1996)

106 90 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Hospital Service Area Resident Population Medicare Enrollees (1992 plus 1993) Price Adjusted Reimbursements for All Services Price Adjusted Reimbursements for Professional and Lab Services Price Adjusted Reimbursements for Inpatient Hospital Services Price Adjusted Reimbursements for Outpatient Facilities AAPCC (1996) Perth Amboy 46,666 11,053 (3,235) 995 2,234 (168) 5,990 4,884 Phillipsburg 66,046 19,428 3,516 1,048 1, ,951 4,835 Plainfield 126,986 29,525 3, , ,480 4,452 Point Pleasant 107,468 40,518 3,287 1,010 1, ,318 4,695 Pompton Plains 105,870 22,020 3,566 1,094 1, ,497 4,466 Princeton 146,406 38,656 2, , ,078 5,237 Rahway 74,247 22,530 2, , ,869 4,768 Red Bank 114,186 29,504 3,418 1,070 1, ,692 5,025 Ridgewood 187,639 52,087 2, , ,554 4,507 Riverside 48,882 13,705 3, ,988 (280) 5,804 5,297 Salem 50,562 14,587 4,623 1,439 2,284 (427) 6,149 5,612 Secaucus 14,061 4,518 (3,872) (1,021) 1,886 (217) 6,064 5,109 Somers Point 62,423 23,808 3,364 1,113 1, ,963 5,383 Somerville 131,320 29,158 3, , ,069 4,132 South Amboy 56,171 13,416 4,156 1,081 2,148 (221) 5,990 4,884 Stratford 161,635 31,458 3, , ,232 5,688 Summit 152,400 47,042 3,239 1,004 1, ,774 4,691 Sussex 44,552 7,495 (3,156) 896 1,665 (242) 5,168 4,199 Teaneck 144,635 44,413 3, , ,562 4,513 Toms River 181, ,579 3,564 1,119 1, ,260 4,643 Trenton 277,421 75,341 3,721 1,053 2, ,265 5,398 Union 89,774 33,308 3, , ,797 4,710 Vineland 64,429 17,820 3,741 1,095 2,094 (322) 5,762 5,609 Wayne 89,417 26,974 3,294 1,022 1, ,489 4,454 Westwood 100,870 26,635 2, , ,562 4,513 Willingboro 81,814 18,005 4,003 1,124 2,068 (264) 5,804 5,297 Woodbury 119,186 29,153 3,464 1,013 2, ,212 5,670 New York Albany 301,861 83,261 2, , ,562 4,400 Alexandria Bay 9,786 2,922 (2,269) (560) 1,323 (258) 3,702 4,046 Amityville 119,243 30,189 3,771 1,237 1, ,755 5,201 Amsterdam 56,147 21,139 2, , ,141 3,995 Auburn 80,425 22,826 2, , ,601 4,680 Batavia 67,447 17,078 2, ,710 (202) 4,436 4,329 Bath 23,737 7,210 (3,216) 818 1,588 (268) 4,210 4,601 Bay Shore 173,014 32,621 3,414 1,159 1, ,433 4,953 Bethpage 130,254 30,961 3,333 1,154 1, ,789 5,227 Binghamton 263,453 75,654 2, , ,279 4,418 Brockport 38,437 5,831 (2,743) (708) 1,748 (294) 4,626 4,515 Bronx 1,118, ,840 4,043 1,039 2, ,804 6,906 Bronxville 63,148 24,296 3,156 1,083 1, ,626 5,197 Brooklyn 2,184, ,498 3,837 1,219 2, ,437 6,618 Buffalo 796, ,096 2, , ,717 4,797 Callicoon 3,588 1,005 (2,991) (783) 2,084 (255) 5,814 6,354 Cambridge 15,274 4,897 (2,990) (848) 1,686 (319) 4,141 4,332 Canandaigua 59,572 13,813 2, ,510 (215) 3,855 3,762 Price-Adjusted AAPCC (1996)

107 THE MEDICARE PROGRAM 91 Hospital Service Area Resident Population Medicare Enrollees (1992 plus 1993) Price Adjusted Reimbursements for All Services Price Adjusted Reimbursements for Professional and Lab Services Price Adjusted Reimbursements for Inpatient Hospital Services Price Adjusted Reimbursements for Outpatient Facilities AAPCC (1996) Carmel 72,211 12,622 4,156 1,199 2,011 (157) 6,686 5,244 Carthage 14,945 3,384 (3,065) (685) 1,751 (499) 3,684 4,026 Catskill 63,896 22,489 3,456 1,029 1, ,376 4,782 Clifton Springs 25,153 6,549 (2,394) (678) 1,728 (260) 3,904 3,809 Cobleskill 23,880 6,820 (2,464) 710 1,583 (279) 4,236 4,086 Cold Spring 4,904 1,452 (1,428) (443) 1,846 (94) 6,761 5,303 Cooperstown 37,599 11,787 (2,866) 590 2,091 (374) 4,472 4,888 Corning 44,951 12,948 2, ,685 (234) 4,200 4,590 Cornwall 63,589 8,943 (3,034) 765 1,784 (192) 5,483 5,019 Cortland 59,359 14,153 3, ,729 (257) 4,364 4,769 Cuba 9,277 2,581 (3,612) (720) 1,698 (197) 4,314 4,715 Dansville 36,386 9,108 (2,771) 708 1,724 (278) 4,520 4,411 Dobbs Ferry 15,425 4,425 (4,817) (1,258) 1,767 (386) 6,626 5,197 Dunkirk 39,633 12,011 2, ,824 (320) 3,938 4,469 East Meadow 105,921 25,430 3,183 1,026 2, ,905 5,316 Elizabethtown 6,009 2,042 (3,054) (693) 1,687 (403) 4,283 4,681 Ellenville 11,280 2,849 (2,365) (782) 2,006 (200) 5,126 5,602 Elmira 99,784 29,680 3, , ,192 4,730 Far Rockaway 134,206 37,353 5,273 1,780 2, ,551 5,923 Flushing 855, ,286 3,656 1,152 2, ,823 6,136 Fulton 32,700 8,408 (3,696) 1,037 1,815 (278) 4,350 4,425 Geneva 48,828 14,636 2, ,579 (358) 4,183 4,082 Glen Cove 72,566 20,844 3, , ,905 5,316 Glens Falls 129,549 33,927 2, , ,217 4,412 Gloversville 46,862 15,906 3, ,730 (315) 4,213 4,604 Goshen 62,879 11,138 (3,184) 893 2,085 (218) 5,483 5,019 Gouverneur 11,757 2,844 (3,767) (885) 2,199 (451) 4,075 4,454 Gowanda 18,266 4,655 (3,384) (887) 1,676 (229) 4,513 4,590 Greenport 16,920 8,790 (2,641) 784 1,436 (239) 6,433 4,953 Hamilton 27,218 6,357 (2,520) (840) 1,609 (308) 4,058 4,127 Harris 50,165 15,251 4,995 1,230 2,452 (435) 5,702 6,232 Hornell 26,700 7,658 (3,126) 549 2,327 (259) 4,215 4,606 Huntington 188,851 39,525 2, , ,433 4,953 Irving 22,699 6,371 (3,854) (1,061) 1,623 (286) 4,494 4,570 Ithaca 94,468 16,963 3, ,600 (263) 4,101 4,482 Jamaica 637, ,824 3, , ,823 6,136 Jamestown 82,572 26,055 3, , ,955 4,488 Kenmore 96,518 29,980 2, , ,717 4,797 Kingston 123,117 33,157 3, , ,102 5,576 Lackawanna 35,685 10,961 (2,554) 770 1,519 (216) 4,717 4,797 Lewiston 57,798 18,960 2, , ,716 4,796 Little Falls 21,245 7,236 (3,771) 845 1,752 (264) 4,053 4,335 Lockport 54,408 14,052 2, ,856 (250) 4,716 4,796 Long Beach 50,754 15,345 4,531 1,427 2,252 (242) 6,905 5,316 Long Island City 142,487 33,868 3, , ,823 6,136 Lowville 20,087 5,428 (3,929) (830) 1,389 (381) 3,684 4,026 Price-Adjusted AAPCC (1996)

108 92 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Hospital Service Area Resident Population Medicare Enrollees (1992 plus 1993) Price Adjusted Reimbursements for All Services Price Adjusted Reimbursements for Professional and Lab Services Price Adjusted Reimbursements for Inpatient Hospital Services Price Adjusted Reimbursements for Outpatient Facilities AAPCC (1996) Malone 31,011 8,203 (3,049) 656 1,920 (251) 4,045 4,421 Manhasset 166,274 52,918 3,422 1,165 1, ,251 5,583 Manhattan 1,812, ,633 4,003 1,150 2, ,542 6,700 Margaretville 9,755 3,279 (3,164) (758) 1,853 (261) 4,525 4,945 Massena 18,095 6,307 (2,905) (735) 1,684 (269) 4,129 4,513 Medina 33,492 9,296 (2,668) 738 1,495 (336) 4,149 4,049 Middletown 90,000 19,195 3, , ,489 5,025 Mineola 177,792 56,078 3,220 1,013 1, ,905 5,316 Montour Falls 12,017 3,770 (2,950) (713) 1,692 (260) 4,061 4,438 Mount Kisco 125,577 28,401 3,076 1,002 1, ,626 5,197 Mount Vernon 68,508 17,210 3,518 1,129 1,985 (250) 6,626 5,197 New Rochelle 92,596 28,045 3,650 1,133 1, ,626 5,197 Newark 34,207 9,463 (2,672) 712 1,655 (263) 3,913 3,819 Newburgh 74,539 19,743 3, , ,418 4,960 Newfane 14,446 3,891 (3,681) (1,010) 1,910 (298) 4,716 4,796 Niagara Falls 47,098 16,204 3, ,886 (488) 4,716 4,796 North Tarrytown 84,804 22,285 2, , ,626 5,197 North Tonawanda 51,399 12,409 2, ,703 (277) 4,716 4,796 Norwich 25,793 7,390 (2,872) 725 1,589 (301) 3,625 3,962 Nyack 163,923 36,325 3,387 1,068 1, ,024 5,509 Oceanside 181,163 44,883 2,925 1,070 1, ,905 5,316 Ogdensburg 30,432 8,037 (3,153) 812 1,591 (605) 4,129 4,513 Olean 64,927 19,274 3, , ,245 4,639 Oneida 39,254 11,216 (3,197) 810 1,783 (283) 4,185 4,256 Oneonta 45,364 12,798 2, ,905 (262) 4,581 5,007 Oswego 45,067 9,887 (2,926) 699 1,792 (296) 4,318 4,391 Patchogue 180,306 30,940 3,229 1,017 1, ,433 4,953 Peekskill 64,274 13,436 3,009 1,037 1,482 (178) 6,650 5,216 Penn Yan 21,208 6,940 (2,823) 656 1,618 (275) 3,601 3,935 Plainview 71,747 20,048 3,392 1,127 1, ,905 5,316 Plattsburgh 93,551 18,818 3, , ,581 5,007 Port Chester 78,825 22,908 3, , ,626 5,197 Port Jefferson 205,525 37,118 3,378 1,063 1, ,433 4,953 Port Jervis 41,762 12,613 3,660 1,013 1,664 (252) 5,448 4,987 Potsdam 47,311 9,455 (2,578) 601 1,452 (361) 4,129 4,513 Poughkeepsie 223,296 47,689 2, , ,104 4,524 Rhinebeck 20,350 6,027 (2,279) (852) 1,356 (189) 5,104 4,524 Riverhead 45,046 16,219 3, ,682 (235) 6,433 4,953 Rochester 749, ,607 3, , ,932 4,813 Rockville Centre 109,692 25,617 3,364 1,112 1, ,905 5,316 Rome 74,756 18,108 2, ,797 (215) 4,121 4,408 Saranac Lake 28,941 8,446 (2,474) 729 1,637 (520) 4,164 4,550 Saratoga Springs 74,178 17,459 2, ,537 (219) 4,438 4,280 Schenectady 222,565 61,491 2, , ,288 4,136 Seaford 21,644 5,659 (3,618) (1,333) 1,680 (158) 6,905 5,316 Sidney 21,082 6,717 (3,002) (711) 1,731 (258) 4,092 4,472 Price-Adjusted AAPCC (1996)

109 THE MEDICARE PROGRAM 93 Hospital Service Area Resident Population Medicare Enrollees (1992 plus 1993) Price Adjusted Reimbursements for All Services Price Adjusted Reimbursements for Professional and Lab Services Price Adjusted Reimbursements for Outpatient Facilities AAPCC (1996) Smithtown 193,056 35,993 3,546 1,157 1, ,433 4,953 Sodus 25,909 6,213 (3,035) (800) 1,791 (247) 3,913 3,819 Southampton 50,342 20,188 2, , ,433 4,953 Springville 27,533 6,920 (2,441) 843 1,552 (188) 4,508 4,584 Star Lake 4,237 1,150 (5,153) (989) 2,340 (378) 4,129 4,513 Staten Island 378,977 75,823 4,527 1,285 2, ,102 7,139 Stony Brook 29,722 4,913 (4,034) (1,139) 1,795 (377) 6,433 4,953 Suffern 104,075 18,842 3,515 1,134 1, ,965 5,463 Syosset 42,890 11,624 (3,240) 1,264 1,740 (209) 6,905 5,316 Syracuse 529, ,757 3, , ,398 4,473 Ticonderoga 11,018 3,643 (2,774) (588) 1,889 (450) 4,267 4,663 Troy 162,165 45,261 3, , ,658 4,493 Utica 211,650 70,132 2, , ,095 4,380 Valley Stream 139,919 40,979 2,968 1,096 1, ,002 5,391 Walton 8,736 2,907 (3,269) (812) 1,716 (353) 4,498 4,915 Warsaw 29,527 7,690 (2,741) 832 2,031 (195) 4,531 4,952 Warwick 24,718 4,894 (4,526) (1,147) 1,817 (268) 5,470 5,007 Watertown 94,139 20,302 2, , ,732 4,079 Wellsville 30,633 8,441 (2,686) 628 1,933 (195) 4,314 4,715 West Islip 193,419 36,617 3,209 1,150 1, ,433 4,953 Westfield 13,435 4,018 (2,538) (609) 1,701 (301) 3,938 4,469 White Plains 136,328 39,141 3, , ,626 5,197 Yonkers 155,725 41,676 3,652 1,131 2, ,626 5,197 Pennsylvania Abington 121,478 37,057 3,767 1,147 1, ,863 5,351 Aliquippa 39,782 13,733 3,819 1,022 2,177 (319) 5,846 5,939 Allentown 309,670 92,683 4,235 1,233 1, ,605 5,581 Altoona 122,103 39,865 4, , ,008 5,814 Ashland 11,324 4,462 (3,523) (708) 2,074 (405) 5,043 5,774 Beaver 112,887 38,148 4,132 1,097 2, ,845 5,937 Berwick 31,816 11,544 (3,938) 978 2,043 (504) 4,977 5,421 Bethlehem 131,579 42,077 4,081 1,107 1, ,833 5,808 Bloomsburg 39,124 10,841 (4,582) 1,022 1,701 (585) 4,831 5,263 Braddock 18,060 6,813 (6,270) 1,532 2,493 (470) 6,704 6,811 Bradford 31,010 9,972 (4,178) 1,184 1,777 (411) 4,568 5,230 Bristol 49,546 11,682 (4,726) 1,471 2,394 (298) 6,430 5,868 Brookville 23,147 8,213 (4,187) 985 2,156 (402) 5,336 6,109 Brownsville 22,037 8,350 (4,444) 794 2,496 (324) 6,223 6,322 Bryn Mawr 124,022 40,650 3,871 1,278 1, ,264 5,717 Butler 76,842 23,575 4,726 1,028 1, ,597 5,686 Camp Hill 146,253 40,672 3, , ,478 4,616 Canonsburg 35,885 10,219 (5,503) 1,415 2,192 (453) 6,139 6,237 Carbondale 26,834 10,631 (4,031) 1,073 1,819 (400) 5,100 5,555 Carlisle 84,070 21,173 3, , ,601 4,743 Chambersburg 95,380 26,483 3, , ,004 4,584 Clarion 32,048 8,121 (5,020) 971 2,425 (546) 5,797 6,638 Price-Adjusted AAPCC (1996)

110 94 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Hospital Service Area Resident Population Medicare Enrollees (1992 plus 1993) Price Adjusted Reimbursements for All Services Price Adjusted Reimbursements for Professional and Lab Services Price Adjusted Reimbursements for Outpatient Facilities AAPCC (1996) Clearfield 42,430 15,094 3, ,041 (369) 5,642 6,460 Coaldale 25,548 11,988 (4,619) 1,138 2,340 (320) 5,268 6,031 Coatesville 62,547 13,861 3,211 1,074 1,854 (293) 5,730 5,230 Connellsville 33,141 10,435 (4,640) 1,022 2,300 (330) 6,469 6,572 Corry 19,138 5,013 (4,009) (884) 2,143 (324) 4,623 5,204 Coudersport 17,492 5,516 (3,203) (837) 1,811 (382) 4,178 4,783 Danville 43,388 17,136 4, ,855 (694) 4,752 5,441 Darby 96,231 24,589 5,077 1,321 2, ,270 6,635 Doylestown 87,671 20,479 3,702 1,133 1, ,430 5,868 Drexel Hill 118,023 37,923 3,786 1,243 1, ,564 5,991 Dubois 43,590 13,975 3, ,819 (447) 5,401 6,184 East Stroudsburg 94,194 26,925 4,633 1,312 1, ,110 6,996 Easton 113,412 35,892 4,051 1,127 2, ,923 5,897 Ellwood City 25,848 8,658 (4,541) 1,008 2,354 (419) 5,726 6,556 Ephrata 53,424 13,302 3, ,480 (336) 4,094 4,311 Erie 261,279 74,193 3,514 1,055 1, ,764 5,362 Everett 33,088 10,719 (4,750) 947 1,938 (589) 4,873 5,580 Franklin 57,411 18,658 4, , ,205 5,960 Gettysburg 46,660 13,133 3, ,753 (394) 4,186 4,793 Greensburg 79,056 29,019 4,540 1,186 2, ,268 6,367 Greenville 47,961 15,442 4,853 1,088 2,127 (493) 5,290 6,113 Grove City 33,561 8,228 (4,119) 958 2,092 (497) 5,394 6,233 Hanover 62,644 19,733 2, , ,176 4,485 Harrisburg 242,452 67,368 4,237 1,001 1, ,370 5,536 Hazleton 75,361 30,867 4,796 1,369 1, ,312 5,787 Hershey 20,756 5,724 (4,929) (901) 1,828 (516) 5,386 5,552 Honesdale 32,549 12,720 3, ,728 (218) 4,696 5,376 Huntingdon 45,166 12,634 3, ,765 (299) 4,732 5,417 Indiana 64,609 16,854 4,339 1,035 2,219 (504) 6,040 6,915 Jeannette 77,271 22,142 4,527 1,270 2, ,268 6,367 Jersey Shore 16,178 4,318 (2,965) (806) 1,736 (424) 4,694 5,141 Johnstown 151,021 56,774 4, , ,912 6,929 Kane 10,176 4,165 (3,905) (957) 1,881 (415) 4,775 5,467 Kingston 36,818 16,685 4,462 1,207 1,652 (507) 5,333 5,809 Kittanning 44,530 16,170 4, ,121 (574) 5,460 6,252 Lancaster 372, ,869 3, , ,102 4,319 Langhorne 237,112 49,700 3,921 1,340 2, ,430 5,868 Lansdale 80,730 19,056 3,765 1,168 1, ,867 5,355 Latrobe 75,759 25,531 4,650 1,088 2, ,229 6,328 Lebanon 119,133 35,713 4, , ,141 4,269 Lehighton 27,820 9,392 (5,109) 1,325 1,801 (313) 5,503 5,478 Lewisburg 72,802 19,730 3, , ,380 5,015 Lewistown 66,249 20,592 3, , ,225 5,982 Lock Haven 32,753 10,232 (4,229) 989 1,795 (357) 4,912 5,624 Mcconnellsburg 13,194 3,375 (6,071) (1,152) 1,894 (445) 4,283 4,904 Mckees Rocks 25,092 9,629 (3,593) 869 2,120 (269) 6,704 6,811 Price-Adjusted AAPCC (1996)

111 THE MEDICARE PROGRAM 95 Hospital Service Area Resident Population Medicare Enrollees (1992 plus 1993) Price Adjusted Reimbursements for All Services Price Adjusted Reimbursements for Professional and Lab Services Price Adjusted Reimbursements for Outpatient Facilities AAPCC (1996) Mckeesport 79,781 33,537 4,620 1,242 2, ,704 6,811 Meadville 66,668 20,987 3,741 1,016 1, ,874 5,580 Media 50,667 16,323 4,747 1,421 2,087 (427) 6,564 5,991 Meyersdale 10,594 3,410 (3,331) (722) 2,034 (346) 5,390 6,318 Monongahela 68,888 33,362 4,755 1,153 2, ,198 6,297 Monroeville 96,344 31,190 5,122 1,437 2, ,547 6,651 Montrose 8,938 3,442 (2,558) (708) 1,653 (255) 4,531 5,188 Mount Pleasant 42,286 14,905 4,831 1,092 2,410 (382) 6,308 6,408 Muncy 27,890 8,012 (3,620) 1,012 1,688 (528) 4,543 4,976 Natrona Heights 92,458 32,755 3,796 1,015 1, ,177 6,275 New Castle 80,724 30,125 4,354 1,059 2, ,699 6,525 New Kensington 41,922 16,893 4,568 1,156 2,059 (416) 6,268 6,367 Norristown 179,653 45,432 4,035 1,169 1, ,863 5,351 Palmerton 17,584 5,615 (3,954) (1,166) 1,869 (271) 5,728 5,703 Paoli 49,988 12,146 4,214 1,202 1,725 (404) 5,730 5,230 Peckville 6,252 2,205 (3,202) (878) 1,617 (258) 5,536 6,030 Philadelphia 1,783, ,174 4,473 1,336 2, ,855 7,169 Philipsburg 14,380 4,699 (3,186) (744) 1,623 (260) 4,908 5,346 Phoenixville 59,102 14,954 3, ,622 (290) 5,774 5,270 Pittsburgh 1,120, ,312 4,854 1,271 2, ,657 6,763 Pottstown 81,454 22,064 2, , ,491 5,012 Pottsville 117,182 46,192 3,983 1,097 1, ,070 5,805 Punxsutawney 21,759 7,526 (4,201) 983 1,843 (406) 5,313 6,083 Quakertown 35,284 8,750 (3,600) 1,115 1,672 (248) 6,430 5,868 Reading 300,097 96,984 3, , ,672 4,772 Renovo 3,848 1,790 (3,202) (724) 2,059 (351) 4,910 5,621 Ridgway 10,769 4,125 (3,459) (810) 2,082 (451) 5,089 5,827 Ridley Park 94,485 28,388 3,790 1,185 2, ,564 5,991 Roaring Spring 23,081 6,543 (3,526) (782) 1,733 (450) 4,868 5,652 Sayre 63,983 18,029 3, ,757 (212) 3,953 4,526 Scranton 222,667 86,546 4,410 1,189 1, ,464 5,952 Sellersville 89,066 21,227 3,598 1,164 1, ,044 5,517 Sewickley 79,854 27,617 3, , ,360 6,461 Shamokin 21,106 9,830 (3,166) 716 1,938 (354) 4,757 5,446 Sharon 53,793 21,877 4,727 1,190 2, ,345 6,176 Somerset 39,440 13,135 4,742 1,038 2,432 (470) 5,390 6,318 Spangler 24,428 8,410 (4,736) 843 2,436 (399) 5,935 6,956 St Marys 25,270 8,361 (4,975) 988 1,818 (648) 4,993 5,717 State College 110,236 19,445 3, , ,603 5,014 Sunbury 48,047 15,069 3, ,942 (501) 4,769 5,460 Susquehanna 12,155 3,886 (4,606) (878) 2,105 (443) 4,528 5,184 Titusville 24,122 7,760 (4,541) 1,041 2,237 (454) 4,606 5,274 Towanda 20,627 6,553 (2,465) (688) 1,685 (178) 3,853 4,411 Tunkhannock 22,387 5,810 (4,246) (984) 1,992 (337) 4,944 5,386 Tyrone 17,259 5,366 (3,490) (827) 2,019 (272) 4,882 5,668 Union City 8,890 2,057 (4,045) (1,114) 1,962 (630) 4,775 5,374 Price-Adjusted AAPCC (1996)

112 96 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Hospital Service Area Resident Population Medicare Enrollees (1992 plus 1993) Price Adjusted Reimbursements for All Services Price Adjusted Reimbursements for Professional and Lab Services Price Adjusted Reimbursements for Outpatient Facilities AAPCC (1996) Uniontown 82,693 29,802 5, , ,469 6,572 Upland 116,969 29,297 4,386 1,209 2, ,564 5,991 Warminster 37,480 6,960 (5,155) 1,373 2,203 (367) 6,430 5,868 Warren 38,240 12,413 3, ,703 (456) 4,231 4,844 Washington 87,504 28,604 4,804 1,160 2, ,139 6,237 Waynesboro 45,794 13,201 3, ,693 (302) 3,884 4,447 Waynesburg 32,933 10,788 (4,722) 853 2,956 (548) 5,945 6,806 Wellsboro 39,437 12,292 3, ,649 (331) 3,938 4,509 West Chester 141,812 29,251 3,648 1,124 1, ,769 5,266 West Grove 41,564 8,533 (3,418) 1,049 2,028 (333) 5,730 5,230 Wilkes-Barre 221,488 82,143 4,220 1,127 1, ,347 5,824 Williamsport 88,829 28,371 3, , ,599 5,037 Windber 16,485 6,684 (3,727) (669) 2,126 (519) 5,390 6,318 York 278,302 75,264 2, , ,211 4,523 Price-Adjusted AAPCC (1996)

113 PART FOUR The Physician Workforce in the Middle Atlantic States This section provides measures of the allocation of physicians who are in active practice to the populations living in the Middle Atlantic States hospital service areas. A physician in active practice is defined as one who reported that he or she spent at least 20 hours a week in patient care. The estimates for the physician workforce per 100,000 take into account patient migration across the boundaries of hospital service areas and have been adjusted for differences in age and sex of the local populations. Part Nine of the national volume of the Dartmouth Atlas of Health Care explains how these adjustments were made. The data, which come from the American Medical Association, the American Osteopathic Association, and the Medicare program, are for The population count is based on the 1990 United States census. The data used for the health maintenance organization benchmark is from a large staff model health maintenance organization. It has been adjusted to account for differences in age and sex according to methods described in Part Nine of the national Atlas. Additional adjustments were made to account for out-of-plan use, as described in the note to Table 4.

114 98 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES The Physician Workforce Active in Patient Care The number of physicians in active practice per hundred thousand residents varied substantially from the national average of 189, and was particularly high in many areas close to metropolitan New York. Among the region s larger hospital service areas, the numbers of physicians were far above the national average in Manhattan (327.8); and Philadelphia (292.4). Camden, New Jersey (242.1); Pittsburgh (227.9); Trenton, New Jersey (225.4); Albany, New York (223.2); New Brunswick, New Jersey (207.3); Rochester, New York (203.7); Buffalo, New York (203.0); and Allentown, Pennsylvania (196.5) were all above the national average. Syracuse, New York (179.4); and Newark, New Jersey (156.8) were below it. All Physicians in Active Practice per 100,000 Residents in HSAs The Middle Atlantic States. The gray horizontal line represents the United States Figure 4.1. Physicians Allocated to Hospital Service Areas in the Middle Atlantic States (1993) The number of physicians in active practice per hundred thousand residents, after adjusting for differences in age and sex of the local population, varied by a factor of more than 4.1. Each point represents one hospital service area.

115 THE PHYSICIAN WORKFORCE 99

116 100 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Specialist Physicians The number of specialist physicians in active practice per hundred thousand residents varied substantially among the Middle Atlantic States, with particularly high numbers in the metropolitan New York region. The numbers of specialists were almost twice as high as the national average of 122 per hundred thousand residents in Manhattan (225.0). Among the region s larger hospital service areas, the numbers of specialists were also above the national average in Philadelphia (192.4); Camden, New Jersey (154.3); Pittsburgh (152.6); Albany, New York (150.2); and Trenton, New Jersey (143.9). New Brunswick, New Jersey (127.9); Rochester, New York (125.7); Allentown, Pennsylvania (122.7); and Syracuse, New York (119.3) were near the national average. Newark, New Jersey (96.6) was substantially below it. Specialists per 100,000 Residents in HSAs The Middle Atlantic States. The gray horizontal line represents the United States average. Figure 4.2. Specialists Allocated to Hospital Service Areas in the Middle Atlantic States (1993) The number of specialist physicians in active practice per hundred thousand residents, after adjusting for differences in age and sex of the local population, varied by a factor of more than 4.4. Each point represents one hospital service area.

117 THE PHYSICIAN WORKFORCE 101

118 102 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Physicians in Primary Care The numbers of primary care physicians in active practice per hundred thousand residents varied by almost as much as the numbers of specialists, and in much the same pattern. Among the region s larger hospital service areas, the numbers of allocated primary care physicians in excess of the national average of 66.0 were Manhattan (100.8); Philadelphia (98.1); Camden, New Jersey (86.7), and Trenton, New Jersey (80.4). New Brunswick, New Jersey (78.3); Rochester, New York (76.8); Pittsburgh (74.0); Allentown, Pennsylvania (73.1); Albany, New York (71.6); and Buffalo, New York (66.2) were close to the national average. Newark, New Jersey (59.2); and Syracuse, New York (59.1) were below it. Primary Care Physicians per 100,000 Residents in HSAs The Middle Atlantic States. The gray horizontal line represents the United States average. Figure 4.3. Primary Care Physicians Allocated to Hospital Service Areas in the Middle Atlantic States(1993) The number of primary care physicians in active practice per hundred thousand residents, after adjusting for differences in age and sex of the local population, varied by a factor of more than 4.2. Each point represents one hospital service area.

119 THE PHYSICIAN WORKFORCE 103

120 104 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Benchmarking: The Physician Workforce Active in Patient Care Figure 4.4. The Total Physician Workforce Allocated to Selected Hospital Service Areas in the Middle Atlantic States Compared to the Highest and Lowest Ranked Selected Areas (1993) The figure gives the ratio of total physicians in selected hospital service areas to the lowest and the highest ranked areas. It also compares each selected area to the U.S. average. The number of physicians above (+) or below (-) the number predicted by the experience in the benchmark area for 1993 is in parentheses. For example, the number of physicians per hundred thousand allocated to the residents of Manhattan was 2.09 times higher than the number allocated to residents of Newark, New Jersey. If the level of physician employment of the Newark benchmark in 1993 had been attained for the residents of Manhattan, 3,099 fewer physicians would have been needed for residents of Manhattan.

121 THE PHYSICIAN WORKFORCE 105 Benchmarking: The Physician Workforce Active in Patient Care Figure 4.5. The Total Physician Workforce Allocated to Selected Hospital Service Areas in the Middle Atlantic States Compared to Selected Hospital Service Areas Elsewhere in the U.S. and to a Large HMO (1993) The figure gives the ratio of total physicians in selected hospital service areas in the Middle Atlantic States to other areas. The number of physicians above (+) or below (-) the number of physicians predicted by the experience in the benchmark area is in parentheses. For example, the number of physicians per hundred thousand allocated to the residents of Manhattan was 2.30 higher than the number allocated to enrollees in the health maintenance organization. If the level of physician employment of the health maintenance organization benchmark in 1993 had been attained for the residents of Manhattan, 3,355 fewer physicians would have been needed in Manhattan. If the San Francisco benchmark had applied, 771 more physicians would have been needed in Manhattan.

122 106 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Benchmarking: Specialists Figure 4.6. Specialist Physicians Allocated to Selected Hospital Service Areas in the Middle Atlantic States Compared to the Highest and Lowest Ranked Selected Areas (1993) The figure gives the ratio of specialist physicians in selected hospital service areas to the lowest and the highest ranked areas. It also compares each selected area to the U.S. average. The number of specialist physicians above (+) or below (-) the number predicted by the experience in the benchmark area for 1993 is in parentheses. For example, the number of specialist physicians per hundred thousand allocated to the residents of Manhattan was 2.33 times higher than the number allocated to residents of Newark, New Jersey. If the level of specialist physician employment of the Newark benchmark in 1993 had been attained for the residents of Manhattan, 2,326 fewer specialists would have been needed in Manhattan.

123 THE PHYSICIAN WORKFORCE 107 Benchmarking: Specialists Figure 4.7. Specialist Physicians Allocated to Selected Hospital Service Areas in the Middle Atlantic States Compared to Selected Hospital Service Areas Elsewhere in the U.S. and to a Large HMO (1993) The figure gives the ratio of specialist physicians in selected hospital service areas in the Middle Atlantic States to other areas. The number of specialist physicians above (+) or below (-) the number of physicians predicted by the experience in the benchmark area is in parentheses. For example, the number of specialists per hundred thousand allocated to the residents of Manhattan was 2.86 higher than the number allocated to enrollees in the health maintenance organization. If the level of specialist physician employment of the health maintenance organization benchmark in 1993 had been attained for the residents of Manhattan, 2,653 fewer specialists would have been needed in Manhattan. If the San Francisco benchmark had applied, 75 fewer specialists would have been needed in Manhattan.

124 108 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Benchmarking: Primary Care Physicians Figure 4.8. Primary Care Physicians Allocated to Selected Hospital Service Areas in the Middle Atlantic States Compared to the Highest and Lowest Ranked Selected Areas (1993) The figure gives the ratio of primary care physicians in selected hospital service areas to the lowest and the highest ranked areas. It also compares each selected area to the U.S. average. The number of primary care physicians above (+) or below (-) the number predicted by the experience in the benchmark area for 1993 is in parentheses. For example, the number of primary care physicians per hundred thousand allocated to the residents of Manhattan was 1.71 times higher than the number allocated to residents of Syracuse, New York. If the level of primary care physician employment of the Syracuse benchmark in 1993 had been attained for the residents of Manhattan, 756 fewer primary care physicians would have been needed in Manhattan.

125 THE PHYSICIAN WORKFORCE 109 Benchmarking: Primary Care Physicians Figure 4.9. Primary Care Physicians Allocated to Selected Hospital Service Areas in the Middle Atlantic States Compared to Selected Hospital Service Areas Elsewhere in the U.S. and to a Large HMO (1993) The figure gives the ratio of primary care physicians in selected hospital service areas in the Middle Atlantic States to other areas. The number of primary care physicians above (+) or below (-) the number predicted by the experience in the benchmark area is in parentheses. For example, the number of primary care physicians per hundred thousand allocated to the residents of Manhattan was 1.84 higher than the number allocated to residents of Houston. If the level of primary care physician employment of the Houston benchmark in 1993 had been attained for the residents of Manhattan, 836 fewer primary care physicians would have been needed in Manhattan. If the San Francisco benchmark had applied, 798 more primary care physicians would have been needed in Manhattan.

126 110 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES TABLE 4 All rates are age and sex adjusted and corrected for out of area use. See Part Nine of the national volume of the Dartmouth Atlas of Health Care for details. The count of primary physicians added to the count of specialists does not equal the count for all physicians; the difference (about 1% nationally) is attributable to those physicians in the All Physician category whose specialty areas were unspecified. Hospital service areas with populations of 5,000 or fewer residents are omitted from the figures and maps. In the table, the data for these areas are in parentheses. The estimates for the staffing patterns of the large health maintenance organization have been adjusted using a.10 adjustment for out-of-plan use and.04 for low Medicaid numbers; i.e., multiplied by a factor of (Weiner JP. Forecasting the Effects of Health Reform on U.S. Physician Workforce Requirement. JAMA. 1994;272: )

127 THE PHYSICIAN WORKFORCE 111 TABLE 4 Physicians in Active Practice Serving Residents of Hospital Service Areas (Physicians per 100,000 population, 1993) Hospital Service Area Resident Population All Physicians Primary Care Physicians Specialists Hospital Service Area Resident Population All Physicians Primary Care Physicians Specialists New Jersey Atlantic City 154, Bayonne 61, Belleville 61, Bridgeton 87, Camden 509, Cape May Court House 70, Denville 104, Dover 139, Edison 175, Elizabeth 189, Elmer 36, Englewood 133, Flemington 96, Freehold 98, Hackensack 137, Hackettstown 40, Hammonton 23, Hoboken 103, Holmdel 111, Irvington 60, Jersey City 228, Kearny 64, Lakewood 125, Livingston 107, Long Branch 78, Manahawkin 57, Montclair 150, Morristown 155, Mount Holly 161, Neptune 116, New Brunswick 282, Newark 317, Newton 72, North Bergen 95, Orange 61, Paramus 25, Passaic 211, Paterson 168, Perth Amboy 46, Phillipsburg 66, Plainfield 126, Point Pleasant 107, Pompton Plains 105, Princeton 146, Rahway 74, Red Bank 114, Ridgewood 187, Riverside 48, Salem 50, Secaucus 14, Somers Point 62, Somerville 131, South Amboy 56, Stratford 161, Summit 152, Sussex 44, Teaneck 144, Toms River 181, Trenton 277, Union 89, Vineland 64, Wayne 89, Westwood 100, Willingboro 81, Woodbury 119, New York Albany 301, Alexandria Bay 9, Amityville 119, Amsterdam 56, Auburn 80, Batavia 67, Bath 23, Bay Shore 173, Bethpage 130, Binghamton 263, Brockport 38,

128 112 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Hospital Service Area Resident Population All Physicians Primary Care Physicians Specialists Hospital Service Area Resident Population All Physicians Primary Care Physicians Specialists Bronx 1,118, Bronxville 63, Brooklyn 2,184, Buffalo 796, Callicoon 3,588 (133.5) (46.8) (86.3) Cambridge 15, Canandaigua 59, Carmel 72, Carthage 14, Catskill 63, Clifton Springs 25, Cobleskill 23, Cold Spring 4,904 (286.6) (111.8) (174.0) Cooperstown 37, Corning 44, Cornwall 63, Cortland 59, Cuba 9, Dansville 36, Dobbs Ferry 15, Dunkirk 39, East Meadow 105, Elizabethtown 6, Ellenville 11, Elmira 99, Far Rockaway 134, Flushing 855, Fulton 32, Geneva 48, Glen Cove 72, Glens Falls 129, Gloversville 46, Goshen 62, Gouverneur 11, Gowanda 18, Greenport 16, Hamilton 27, Harris 50, Hornell 26, Huntington 188, Irving 22, Ithaca 94, Jamaica 637, Jamestown 82, Kenmore 96, Kingston 123, Lackawanna 35, Lewiston 57, Little Falls 21, Lockport 54, Long Beach 50, Long Island City 142, Lowville 20, Malone 31, Manhasset 166, Margaretville 9, Massena 18, Medina 33, Middletown 90, Mineola 177, Montour Falls 12, Mount Kisco 125, Mount Vernon 68, New Rochelle 92, New York 1,812, Newark 34, Newburgh 74, Newfane 14, Niagara Falls 47, North Tarrytown 84, North Tonawanda 51, Norwich 25, Nyack 163, Oceanside 181, Ogdensburg 30, Olean 64, Oneida 39, Oneonta 45, Oswego 45, Patchogue 180, Peekskill 64, Penn Yan 21, Plainview 71, Plattsburgh 93, Port Chester 78, Port Jefferson 205, Port Jervis 41, Potsdam 47, Poughkeepsie 223, Rhinebeck 20, Riverhead 45, Rochester 749, Rockville Centre 109, Rome 74,

129 THE PHYSICIAN WORKFORCE 113 Hospital Service Area Resident Population All Physicians Primary Care Physicians Specialists Hospital Service Area Resident Population All Physicians Primary Care Physicians Specialists Saranac Lake 28, Saratoga Springs 74, Schenectady 222, Seaford 21, Sidney 21, Smithtown 193, Sodus 25, Southampton 50, Springville 27, Star Lake 4,237 (228.8) (92.2) (135.2) Staten Island 378, Stony Brook 29, Suffern 104, Syosset 42, Syracuse 529, Ticonderoga 11, Troy 162, Utica 211, Valley Stream 139, Walton 8, Warsaw 29, Warwick 24, Watertown 94, Wellsville 30, West Islip 193, Westfield 13, White Plains 136, Yonkers 155, Pennsylvania Abington 121, Aliquippa 39, Allentown 309, Altoona 122, Ashland 11, Beaver 112, Berwick 31, Bethlehem 131, Bloomsburg 39, Braddock 18, Bradford 31, Bristol 49, Brookville 23, Brownsville 22, Bryn Mawr 124, Butler 76, Camp Hill 146, Canonsburg 35, Carbondale 26, Carlisle 84, Chambersburg 95, Clarion 32, Clearfield 42, Coaldale 25, Coatesville 62, Connellsville 33, Corry 19, Coudersport 17, Danville 43, Darby 96, Doylestown 87, Drexel Hill 118, Dubois 43, East Stroudsburg 94, Easton 113, Ellwood City 25, Ephrata 53, Erie 261, Everett 33, Franklin 57, Gettysburg 46, Greensburg 79, Greenville 47, Grove City 33, Hanover 62, Harrisburg 242, Hazleton 75, Hershey 20, Honesdale 32, Huntingdon 45, Indiana 64, Jeannette 77, Jersey Shore 16, Johnstown 151, Kane 10, Kingston 36, Kittanning 44, Lancaster 372, Langhorne 237, Lansdale 80, Latrobe 75, Lebanon 119, Lehighton 27, Lewisburg 72, Lewistown 66,

130 114 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Hospital Service Area Resident Population All Physicians Primary Care Physicians Specialists Hospital Service Area Resident Population All Physicians Primary Care Physicians Specialists Lock Haven 32, Mcconnellsburg 13, Mckees Rocks 25, Mckeesport 79, Meadville 66, Media 50, Meyersdale 10, Monongahela 68, Monroeville 96, Montrose 8, Mount Pleasant 42, Muncy 27, Natrona Heights 92, New Castle 80, New Kensington 41, Norristown 179, Palmerton 17, Paoli 49, Peckville 6, Philadelphia 1,783, Philipsburg 14, Phoenixville 59, Pittsburgh 1,120, Pottstown 81, Pottsville 117, Punxsutawney 21, Quakertown 35, Reading 300, Renovo 3,848 (175.1) (67.4) (107.0) Ridgway 10, Ridley Park 94, Roaring Spring 23, Sayre 63, Scranton 222, Sellersville 89, Sewickley 79, Shamokin 21, Sharon 53, Somerset 39, Spangler 24, St Marys 25, State College 110, Sunbury 48, Susquehanna 12, Titusville 24, Towanda 20, Tunkhannock 22, Tyrone 17, Union City 8, Uniontown 82, Upland 116, Warminster 37, Warren 38, Washington 87, Waynesboro 45, Waynesburg 32, Wellsboro 39, West Chester 141, West Grove 41, Wilkes-Barre 221, Williamsport 88, Windber 16, York 278,

131 PART FIVE The Utilization of Hospitals for Medical and Surgical Conditions This section of the Atlas provides overall measures of the use of hospitals for medical and surgical discharges, as well as procedure rates for selected conditions. As described in Part Two of the national volume of the Dartmouth Atlas of Health Care, variations in the rates of use of hospitals for medical discharges are closely related to the capacity of the hospital industry in local and regional markets. Supplyrelated variations in the use of specific surgical procedures, while linked to the quantity of resources, also reflect scientific uncertainty about the outcomes of alternative ways of treating common conditions whether to treat coronary artery disease medically or surgically, for example. These variations also reflect a common failure to adequately involve patients in making decisions about treatment choices. Part Six of the national volume of the Atlas discusses these sources of variation in more detail to raise the question Which rate is right? The wide variations in surgical procedure rates in the region make clear the relevance of the question for the Middle Atlantic States. This section of the Atlas is based on data from the Medicare program for

132 116 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Total Medicare Discharges The total number of discharges per thousand Medicare enrollees varied substantially among and within the Middle Atlantic States. Among the region s larger hospital service areas, the numbers of discharges were higher than the national average of 315 per thousand enrollees in Newark, New Jersey (394.1); Pittsburgh (388.4); Philadelphia (373.3); Camden, New Jersey (362.4); and Staten Island, New York (358.8). In New York State, the hospital service areas in Brooklyn (299.7); Buffalo (277.1); Manhattan (270.9); Rochester (262.2); and Syracuse (254.0) were all below the national average. All Discharges per 1,000 Medicare Enrollees in HSAs The Middle Atlantic States. The gray horizontal line represents the United States average. Figure 5.1. All Discharges per 1,000 Medicare Enrollees in Hospital Service Areas in the Middle Atlantic States ( ) The number of discharges per thousand Medicare enrollees varied by a factor of more than 1.7. Each point represents one hospital service area.

133 THE UTILIZATION OF HOSPITALS FOR MEDICAL AND SURGICAL CONDITIONS 117

134 118 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Medicare Discharges for Medical Conditions The number of discharges for medical conditions per thousand Medicare enrollees varied substantially among the Middle Atlantic States, but the majority of hospital service areas were above the national average of 220 per thousand enrollees. Among the region s larger hospital service areas with particularly high rates of discharges for medical conditions were Newark, New Jersey (286.2) and Pittsburgh (280.1). New Brunswick, New Jersey (233.0) was near the national average. In New York State, the hospital service areas in Brooklyn (208.1); Buffalo (192.1); Manhattan (183.2); Rochester (171.6); and Syracuse (166.6) were below it. Medical Discharges per 1,000 Medicare Enrollees in HSAs The Middle Atlantic States. The gray horizontal line represents the United States average. Figure 5.2. Medical Discharges per 1,000 Medicare Enrollees in Hospital Service Areas in the Middle Atlantic States ( ) The number of discharges for medical conditions per thousand Medicare enrollees varied by a factor of more than 2.3. Each point represents one hospital service area.

135 THE UTILIZATION OF HOSPITALS FOR MEDICAL AND SURGICAL CONDITIONS 119

136 120 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Medicare Discharges for Surgical Procedures The numbers of surgical discharges per thousand Medicare enrollees were generally higher in hospital service areas in New Jersey and Pennsylvania than in New York State. Among the region s larger hospital service areas, the numbers of surgical discharges were above the national average of 95.1 per thousand enrollees in Philadelphia (109.1); Pittsburgh (108.3); Newark, New Jersey (106.2), and Camden, New Jersey (102.4). New Brunswick, New Jersey (97.2) and Staten Island, New York (97.2) were near the national average. In New York State, the hospital service areas in Brooklyn (91.7); the Bronx (91.6); Rochester (90.7); Manhattan (88.2); Syracuse (87.2); and Buffalo (85.0) were all below the national average. Surgical Discharges per 1,000 Medicare Enrollees in HSAs The Middle Atlantic States. The gray horizontal line represents the United States average. Figure 5.3. Surgical Discharges per 1,000 Medicare Enrollees in Hospital Service Areas in the Middle Atlantic States ( ) The number of surgical discharges per thousand Medicare enrollees varied by a factor of more than 1.7. Each point represents one hospital service area.

137 THE UTILIZATION OF HOSPITALS FOR MEDICAL AND SURGICAL CONDITIONS 121

138 122 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Medicare Discharges for High Variation Medical Conditions More than 80% of medical admissions are for the treatment of what have been described as high variation medical conditions, including problems such as pneumonia, chronic obstructive pulmonary disease, gastroenteritis, and congestive heart failure. Residents of areas with higher hospital capacity experienced greater use of hospital care, particularly for high variation medical conditions. Among the larger hospital service areas in the Middle Atlantic States, the numbers of discharges for high variation medical conditions were substantially above the national average of 191 per thousand enrollees in Newark, New Jersey (258.0); Pittsburgh (246.8), and Philadelphia (231.3). In New York State, Brooklyn (182.1); Buffalo (163.9); Manhattan (161.8); Rochester (145.3); and Syracuse (143.4) were all below the national average. Discharges for HVMCs per 1,000 Medicare Enrollees in HSAs The Middle Atlantic States. The gray horizontal line represents the United States average. Figure 5.4. Discharges for High Variation Medical Conditions per 1,000 Medicare Enrollees in Hospital Service Areas in the Middle Atlantic States ( ) Discharges for high variation medical conditions per thousand Medicare enrollees varied by a factor of more than 2.2. Each point represents one hospital service area.

139 THE UTILIZATION OF HOSPITALS FOR MEDICAL AND SURGICAL CONDITIONS 123

140 124 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Contribution of Discharge Rate and Average Length of Stay to Patient Days of Hospitalization for High Variation Medical Conditions As shown in Part Two of the national Atlas, the rates of hospitalization for high variation medical conditions in hospital service areas are closely associated with the numbers of beds per thousand residents. Greater numbers of available beds reduce the threshold for admission and re-admission. Although health services research has consistently shown that admission policies are more important than length of stay in determining aggregate hospital resource use, length of stay continues to be used as a measure of hospital efficiency. Figures 5.5 and 5.6 illustrate the importance of discharge rates as determinants of hospital use for high variation medical conditions. The variation in bed use was associated almost as strongly with the decsion to admit (as measured by the discharge rate) as with decisions on how long to keep patients in the hospital.

141 THE UTILIZATION OF HOSPITALS FOR MEDICAL AND SURGICAL CONDITIONS 125 Patient Days of Hospitalization for High Variation Medical Conditions per 1,000 Medicare Enrollee in Hospital Service Areas Discharges for HVMCs per 1,000 Medicare Enrollees in HSAs Figure 5.5. The Relationship Between Discharge Rate for High Variation Medical Conditions and Total Hospital Days in Hospital Service Areas in the Middle Atlantic States Variation in hospital days for high variation medical conditions among hospital service areas is associated with differences in discharge rates (R 2 =.34) Patient Days of Hospitalization for High Variation Medical Conditions per 1,000 Medicare Enrollee in Hospital Service Areas Length of Stay for HVMCs per 1,000 Medicare Enrollees in HSAs Figure 5.6. The Relationship Between Average Length of Stay (in Days) for High Variation Medical Conditions and Total Hospital Days in Hospital Service Areas in the Middle Atlantic States The average length of stay in the Middle Atlantic States explains only slightly more of the variation in bed use for high variation medical conditions among hospital service areas (R 2 =.39) than the area s discharge rate.

142 126 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Benchmarking: Discharges for Surgical Procedures Figure 5.7. Discharges for Surgical Procedures per 1,000 Medicare Enrollees in Selected Hospital Service Areas in the Middle Atlantic States Compared to the Highest and Lowest Ranked Selected Hospital Service Areas ( ) The figure gives the ratio of discharges for surgical procedures in selected hospital service areas to the lowest and the highest ranked areas. It also compares each selected area to the U.S. average. The number of surgical discharges above (+) or below (-) the number predicted by the experience in the benchmark area for is in parentheses. For example, the number of surgical discharges per 1,000 Medicare enrollees allocated to the residents of Philadelphia was 1.28 times higher than the number allocated to residents of Buffalo, New York. If the level of hospitalization of the Buffalo benchmark in had been attained for the residents of Philadelphia, 12,060 fewer discharges would have occurred in Philadelphia.

143 THE UTILIZATION OF HOSPITALS FOR MEDICAL AND SURGICAL CONDITIONS 127 Benchmarking: Discharges for Surgical Procedures Figure 5.8. Discharges for Surgical Procedures per 1,000 Medicare Enrollees in Selected Hospital Service Areas in the Middle Atlantic States Compared to Selected Hospital Service Areas Elsewhere in the U.S. ( ) The figure gives the ratio of discharges for surgical procedures in selected hospital service areas in the Middle Atlantic States to other areas. The number of surgical discharges above (+) or below (-) the number predicted by the experience in the benchmark area is in parentheses. For example, the number of surgical discharges per 1,000 Medicare enrollees allocated to the residents of Philadelphia was 1.30 higher than the number allocated to residents of New Haven, Connecticut. If the level of hospitalization of the New Haven benchmark in had been attained for the residents of Philadelphia, 12,619 fewer discharges would have occurred in Philadelphia. If the Los Angeles benchmark had applied, 5,306 fewer discharges would have occurred in Philadelphia.

144 128 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Benchmarking: Discharges for High Variation Medical Conditions Figure 5.9. Discharges for High Variation Medical Conditions per 1,000 Medicare Enrollees in Selected Hospital Service Areas in the Middle Atlantic States Compared to the Highest and Lowest Ranked Selected Hospital Service Areas ( ) The figure gives the ratio of discharges for high variation medical conditions in selected hospital service areas to the lowest and the highest ranked areas. It also compares each selected area to the U.S. average. The number of discharges for high variation medical conditions above (+) or below (-) the number predicted by the experience in the benchmark area for is in parentheses. For example, the number of discharges per 1,000 Medicare enrollees allocated to the residents of Newark, New Jersey was 1.80 times higher than the number allocated to residents of Syracuse, New York. If the level of hospitalization of the Syracuse benchmark in had been attained for the residents of Newark, 6,012 fewer discharges would have occurred in Newark.

145 THE UTILIZATION OF HOSPITALS FOR MEDICAL AND SURGICAL CONDITIONS 129 Benchmarking: High Variation Medical Conditions Figure Discharges for High Variation Medical Conditions per 1,000 Medicare Enrollees in Hospital Service Areas in the Middle Atlantic States Compared to Selected Hospital Service Areas Elsewhere in the U.S. ( ) The figure gives the ratio of discharges for high variation medical conditions in selected hospital service areas in the Middle Atlantic States to other areas. The number of discharges for high variation medical conditions above (+) or below (-) the number predicted by the experience in the benchmark area is in parentheses. For example, the number of discharges per 1,000 Medicare enrollees allocated to the residents of Newark, New Jersey was 1.99 times higher than the number allocated to residents of New Haven, Connecticut. If the level of hospitalization of the New Haven benchmark in had been attained for the residents of Newark, 6,743 fewer discharges would have occurred among Newark residents. If the Chicago benchmark had applied, 1,221 fewer discharges would have occurred among Newark residents.

146 130 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Coronary Artery Bypass Grafting Rates of coronary artery bypass grafting per thousand Medicare enrollees exhibited substantial variation in all three of the Middle Atlantic States. Among the region s larger hospital service areas with rates of coronary artery bypass grafting higher than the national average of 5.2 procedures per thousand Medicare enrollees were Philadelphia (5.8) and Pittsburgh (5.5). Albany, New York (5.0); Manhattan (3.5); and Newark, New Jersey (3.3) were all below the national average. CABG Procedures per 1,000 Medicare Enrollees in HSAs The Middle Atlantic States. The gray horizontal line represents the United States average. Figure Rates of Coronary Artery Bypass Grafting Procedures per 1,000 Medicare Enrollees in Hospital Service Areas in the Middle Atlantic States ( ) Rates of coronary artery bypass grafting per thousand Medicare enrollees varied by a factor of more than 4.1. Each point represents one hospital service area.

147 THE UTILIZATION OF HOSPITALS FOR MEDICAL AND SURGICAL CONDITIONS 131

148 132 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Percutaneous Transluminal Coronary Angioplasty Rates of angioplasty per thousand Medicare enrollees, while variable within all of the Middle Atlantic States, tended to be lower than the national average in New York State. Among the region s larger hospital service areas, rates of angioplasty were higher than the national average of 4.9 procedures per thousand enrollees in Lancaster, Pennsylvania (6.2); Pittsburgh (6.1); and New Brunswick, New Jersey. Rates of angioplasty were lower than the national average in Stratford, New Jersey (4.3) and Princeton, New Jersey (4.1). Among large hospital service areas in New York State, there were a number that were substantially lower than the national average, including Brooklyn (3.1); Syracuse (3.0); Staten Island (2.7); Manhattan (2.6); and Rochester (2.4). PTCA Procedures per 1,000 Medicare Enrollees in HSAs The Middle Atlantic States. The gray horizontal line represents the United States average. Figure Rates of Percutaneous Transluminal Coronary Angioplasty Procedures per 1,000 Medicare Enrollees in Hospital Service Areas in the Middle Atlantic States ( ) Rates of angioplasty varied by a factor of more than Each point represents one hospital service area.

149 THE UTILIZATION OF HOSPITALS FOR MEDICAL AND SURGICAL CONDITIONS 133

150 134 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Coronary Angiography Rates of coronary angiography varied substantially within the region. The hospital service area in Pittsburgh, with 11.6 angiographies per thousand Medicare enrollees, was almost twice as high as Manhattan (6.1). Rochester, New York (7.5) also had lower rates of angiography than other large hospital service areas in the Middle Atlantic States. Coronary angiography is an essential diagnostic step in the decision making process leading to the recommendation of CABG or PTCA procedures. In the Middle Atlantic States, hospital service areas that performed more diagnostic tests for coronary artery disease per thousand Medicare enrollees had higher rates of invasive treatment. CABG and PTCA Procedures per 1,000 Medicare Enrollees in HSAs Rates of Coronary Angiography per 1,000 Medicare Enrollees in Hospital Service Areas in the Middle Atlantic States Figure The Association Between Rates of Coronary Angiography and the Combined Rates of Coronary Artery Bypass Grafting and Coronary Angiography Procedures per 1,000 Medicare Enrollees in Hospital Service Areas in the Middle Atlantic States ( ) The number of Medicare enrollees undergoing invasive cardiovascular procedures was closely linked with the rate of diagnostic testing (R 2 =.70)

151 THE UTILIZATION OF HOSPITALS FOR MEDICAL AND SURGICAL CONDITIONS 135

152 136 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Back Surgery There was substantial variation in rates of back surgery per thousand Medicare enrollees among the Middle Atlantic States, although hospital service areas in New York and New Jersey tended to be below the national average of 2.7 procedures per thousand Medicare enrollees. Among the region s larger hospital service areas, rates of back surgery were above the national average in Lancaster, Pennsylvania (4.7) and Pittsburgh (3.0). Rates were lower than the national average in hospital service areas including Philadelphia (2.0); Syracuse, New York (1.7); Newark, New Jersey (1.4); Manhattan (1.4); Stratford, New Jersey (1.4); Brooklyn, New York (1.1); and Staten Island, New York (0.8). Back Surgery Procedures per 1,000 Medicare Enrollees in HSAs The Middle Atlantic States. The gray horizontal line represents the United States average. Figure Rates of Back Surgery Procedures per 1,000 Medicare Enrollees in Hospital Service Areas in the Middle Atlantic States ( ) Rates of back surgery varied by a factor of more than 8. Each point represents one hospital service area.

153 THE UTILIZATION OF HOSPITALS FOR MEDICAL AND SURGICAL CONDITIONS 137

154 138 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Transurethral Resection of the Prostate for Benign Prostatic Hyperplasia Rates of transurethral resection of the prostate per thousand male Medicare enrollees were extremely variable among the among the Middle Atlantic States. Among the region s larger hospital service areas, rates of transurethral resection of the prostate were higher than the national average of 12.9 per thousand male Medicare enrollees in Newark, New Jersey (17.1); Princeton, New Jersey (15.3); Stratford, New Jersey (15.2); and Brooklyn, New York (15.0). Rates were lower than the national average in Lancaster, Pennsylvania (11.9); Pittsburgh (11.8); Rochester, New York (11.4); New Brunswick, New Jersey (11.1); Manhattan (10.2); and Syracuse, New York (8.7). TURP Procedures for BPH per 1,000 Male Medicare Enrollees in HSAs The Middle Atlantic States. The gray horizontal line represents the United States average. Figure Rates of Transurethral Resection of the Prostate for Benign Prostatic Hyperplasia per 1,000 Male Medicare Enrollees Allocated to Hospital Service Areas in the Middle Atlantic States ( ) Rates of transurethral resection of the prostate per thousand male Medicare enrollees varied by a factor of more than 5.6. Each point represents one hospital service area.