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

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

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 1-55648-172-1 (softcover) 1. Medical care United States Marketing Maps. 2. Health facilities United States Statistics. I. Title. G1201.E5D3 1996 (G&M) 362.1'0973'022 dc20 96-11510 CIP MAP Catalog no. 044202 1996 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

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.

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

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

vi The Center for the Evaluative Clinical Sciences Dartmouth Medical School Hanover, New Hampshire 03755-3863 (603) 650-1820 http://www.dartmouth.edu/~atlas/ 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

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

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 (1992-93) 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

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 (1992-93) 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

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 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39

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 43 45 47 49 3.1 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 67 69 71 73 75 77 79 4.1 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 99 101 103 117 119 121 123 131 133 135 137 139

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 6 42 44 46 48 50 51 52 53 54 55 56

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 (1992-93) 3.2 Price Adjusted Part B Medicare Reimbursements for Professional and Laboratory Services In Hospital Service Areas (1992-93) 3.3 Price Adjusted Medicare Reimbursements for Inpatient Hospital Services per Medicare Enrollee in Hospital Service Areas (1992-93) 3.4 Price Adjusted Medicare Reimbursements for Outpatient Services In Hospital Service Areas (1992-93) 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 (1992-93) 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. (1992-93) 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 (1992-93) 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. (1992-93) 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. 3.11 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. 3.13 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) 57 66 68 70 72 74 80 81 82 83 84 85 86 87 98 100 102

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 (1992-93) 5.2 Medical Discharges per 1,000 Medicare Enrollees in Hospital Service Areas in the Middle Atlantic States (1992-93) 5.3 Surgical Discharges per 1,000 Medicare Enrollees in Hospital Service Areas in the Middle Atlantic States (1992-93) 5.4 Discharges for High Variation Medical Conditions per 1,000 Medicare Enrollees in Hospital Service Areas in the Middle Atlantic States (1992-93) 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 (1992-93) 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 (1992-93) 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 (1992-93) 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. (1992-93) 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 (1992-93) 104 105 106 107 108 109 116 118 120 122 125 125 126 127 128

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. (1992-93) 5.11 Rates of Coronary Artery Bypass Grafting Procedures per 1,000 Medicare Enrollees in Hospital Service Areas in the Middle Atlantic States (1992-93) 5.12 Rates of Percutaneous Transluminal Coronary Angioplasty Procedures per 1,000 Medicare Enrollees in Hospital Service Areas in the Middle Atlantic States (1992-93) 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 (1992-93) 5.14 Rates of Back Surgery Procedures per 1,000 Medicare Enrollees in Hospital Service Areas in the Middle Atlantic States (1992-93) 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 (1992-93) 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 (1992-93) 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. (1992-93) 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 (1992-93) 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. (1992-93) 129 130 132 134 136 138 140 141 142 143

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 (1992-93) 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 (1992-93) 6 Hospital Bed Allocation and Medicare Reimbursements for Inpatient Services by Hospital Service Area and Hospital by Location 3 59 89 111 145 163

Introduction

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,

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

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.

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: 3.712 x 768,694 = 2,853.4. 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: 2,853.4-1,847.9 = 1,005.5. 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

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 (http://www.dartmouth.edu/~atlas/), 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.

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 (1992-93); 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, 1992-93.

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.

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.

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 http://www.dartmouth.edu/~atlas.

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

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

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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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.

ACUTE CARE HOSPITAL RESOURCES AND EXPENDITURES 43

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.

ACUTE CARE HOSPITAL RESOURCES AND EXPENDITURES 45

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.

ACUTE CARE HOSPITAL RESOURCES AND EXPENDITURES 47

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.

ACUTE CARE HOSPITAL RESOURCES AND EXPENDITURES 49

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.

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.

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.

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.

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.

ACUTE CARE HOSPITAL RESOURCES AND EXPENDITURES 55 Benchmarking: Hospital-Based Registered Nurses Figure 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) 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.

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.

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.

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.

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 154,316 3.6 15.9 4.5 1,115 Bayonne 61,444 4.9 18.0 4.0 1,114 Belleville 61,365 4.4 14.5 3.6 916 Bridgeton 87,961 3.6 14.8 3.4 1,003 Camden 509,238 3.5 16.0 4.4 1,152 Cape May Court House 70,984 3.8 15.2 4.2 1,096 Denville 104,485 3.5 13.9 3.1 1,028 Dover 139,426 3.2 10.7 2.4 714 Edison 175,032 2.9 12.9 3.1 775 Elizabeth 189,124 4.4 19.4 4.2 1,099 Elmer 36,897 3.0 12.0 3.2 762 Englewood 133,340 3.5 13.7 3.7 874 Flemington 96,472 2.5 11.1 2.4 662 Freehold 98,712 3.3 15.5 3.3 977 Hackensack 137,814 3.1 15.9 4.7 977 Hackettstown 40,212 2.9 10.3 2.0 636 Hammonton 23,068 4.9 18.0 3.9 1,222 Hoboken 103,043 4.4 13.7 2.7 918 Holmdel 111,073 3.2 11.8 2.7 734 Irvington 60,986 4.1 18.4 4.1 1,120 Jersey City 228,537 5.6 19.5 4.5 1,407 Kearny 64,085 4.0 13.8 3.3 900 Lakewood 125,880 3.2 14.1 3.3 849 Livingston 107,839 3.6 14.3 3.4 1,074 Long Branch 78,311 4.3 19.6 4.7 1,292 Manahawkin 57,947 2.8 12.4 3.0 823 Montclair 150,696 3.2 12.1 2.7 826 Morristown 155,945 2.8 11.1 2.3 814 Mount Holly 161,533 3.2 15.9 3.8 1,164 Neptune 116,432 3.7 16.2 3.5 1,114 New Brunswick 282,900 3.1 15.1 3.7 949 Newark 317,309 6.6 29.0 6.8 1,924 Newton 72,874 3.3 12.8 2.4 764 North Bergen 95,558 3.8 12.8 3.1 893 Orange 61,407 5.0 21.5 4.9 1,340 Paramus 25,085 6.3 26.0 6.2 1,474 Passaic 211,422 3.8 15.6 3.9 922 Paterson 168,959 4.0 17.4 4.1 1,091 Perth Amboy 46,666 4.8 18.6 3.9 1,110 Phillipsburg 66,046 4.0 15.1 3.8 821 Plainfield 126,986 2.9 13.4 3.4 782 Point Pleasant 107,468 3.2 14.4 3.7 843 Pompton Plains 105,870 3.5 13.5 3.2 828 Princeton 146,406 2.8 12.0 3.2 791 Rahway 74,247 3.8 15.0 3.8 912 Red Bank 114,186 3.9 15.1 3.2 936 Ridgewood 187,639 2.5 11.3 3.1 707 Riverside 48,882 4.1 14.5 3.3 1,052 Salem 50,562 3.9 18.4 5.1 1,251 Secaucus 14,061 5.5 19.5 5.0 1,325 Somers Point 62,423 3.6 16.5 4.4 1,129 Somerville 131,320 3.0 11.7 2.8 684 South Amboy 56,171 4.3 17.1 3.3 934 Stratford 161,635 3.2 13.5 3.7 938 Summit 152,400 2.9 14.2 3.3 880 Sussex 44,552 3.3 14.1 2.3 671 Teaneck 144,635 3.7 15.2 4.0 941 Toms River 181,765 3.1 12.9 3.4 825 Trenton 277,421 4.6 18.4 4.5 1,123 Union 89,774 3.9 17.2 3.9 1,052 Vineland 64,429 4.0 15.1 3.7 1,099 Wayne 89,417 3.2 13.9 3.1 837 Westwood 100,870 3.2 12.3 3.3 787 Willingboro 81,814 4.1 16.7 3.9 1,164 Woodbury 119,186 3.3 13.6 3.7 908 New York Albany 301,861 2.9 13.2 3.2 886 Alexandria Bay 9,786 3.7 15.2 3.4 906 Amityville 119,243 3.6 12.8 3.1 708 Amsterdam 56,147 4.0 19.1 3.9 1,158 Auburn 80,425 3.6 13.0 3.0 756 Batavia 67,447 3.3 14.8 3.7 763 Bath 23,737 3.8 14.8 3.9 817 Bay Shore 173,014 3.3 11.4 2.7 702 Bethpage 130,254 3.2 12.0 3.1 803 Binghamton 263,453 2.7 12.3 2.9 851 Brockport 38,437 1.9 9.4 2.2 566

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 1,118,765 5.1 27.7 5.6 1,760 Bronxville 63,148 3.8 15.2 4.3 972 Brooklyn 2,184,026 4.3 20.4 4.3 1,266 Buffalo 796,974 3.8 18.2 4.2 1,106 Callicoon 3,588 4.0 12.9 3.4 928 Cambridge 15,274 4.5 17.6 2.9 977 Canandaigua 59,572 2.7 13.6 2.7 726 Carmel 72,211 3.2 13.0 3.8 794 Carthage 14,945 3.8 16.2 3.2 1,040 Catskill 63,896 2.9 12.1 2.6 873 Clifton Springs 25,153 4.0 16.0 3.2 846 Cobleskill 23,880 3.6 16.0 3.4 991 Cold Spring 4,904 2.5 13.8 3.8 940 Cooperstown 37,599 3.0 21.8 3.4 1,485 Corning 44,951 3.8 14.3 3.9 862 Cornwall 63,589 2.2 8.1 2.2 531 Cortland 59,359 3.6 13.6 3.2 778 Cuba 9,277 3.7 16.6 3.7 957 Dansville 36,386 3.3 14.9 3.5 813 Dobbs Ferry 15,425 3.0 11.7 2.8 784 Dunkirk 39,633 3.9 13.7 3.4 907 East Meadow 105,921 4.7 20.6 5.0 1,445 Elizabethtown 6,009 3.9 14.9 3.3 902 Ellenville 11,280 4.4 13.2 3.3 983 Elmira 99,784 3.5 15.0 3.7 1,043 Far Rockaway 134,206 5.6 23.1 5.4 1,418 Flushing 855,174 3.4 16.9 4.0 1,120 Fulton 32,700 3.3 14.4 3.2 896 Geneva 48,828 3.3 15.2 3.7 857 Glen Cove 72,566 3.1 12.1 3.2 793 Glens Falls 129,549 3.6 13.6 3.1 828 Gloversville 46,862 3.1 14.0 3.0 944 Goshen 62,879 3.8 13.9 3.3 902 Gouverneur 11,757 5.0 20.3 4.2 1,112 Gowanda 18,266 3.7 15.2 3.1 770 Greenport 16,920 4.0 14.1 3.4 896 Hamilton 27,218 2.7 13.8 3.1 900 Harris 50,165 5.9 19.8 5.6 1,534 Hornell 26,700 5.5 22.4 5.2 1,223 Huntington 188,851 2.2 8.7 1.9 518 Irving 22,699 3.1 15.1 3.1 826 Ithaca 94,468 2.7 9.4 2.4 629 Jamaica 637,762 3.5 17.7 3.9 1,113 Jamestown 82,572 3.9 14.3 3.7 777 Kenmore 96,518 2.8 13.3 3.1 787 Kingston 123,117 3.3 11.0 3.2 830 Lackawanna 35,685 3.0 12.2 2.6 753 Lewiston 57,798 3.8 14.6 3.2 814 Little Falls 21,245 3.5 15.1 3.8 832 Lockport 54,408 3.5 12.9 3.2 820 Long Beach 50,754 3.6 13.2 3.6 883 Long Island City 142,487 3.1 13.4 3.3 917 Lowville 20,087 3.5 14.6 3.3 1,102 Malone 31,011 4.1 17.1 3.7 1,034 Manhasset 166,274 2.7 14.7 4.1 997 Margaretville 9,755 2.9 15.9 3.1 1,018 Massena 18,095 3.6 17.8 4.6 1,230 Medina 33,492 3.1 14.1 3.2 760 Middletown 90,000 3.6 12.1 3.5 842 Mineola 177,792 3.2 15.4 3.9 1,000 Montour Falls 12,017 4.1 18.4 4.0 1,274 Mount Kisco 125,577 2.8 11.4 3.5 732 Mount Vernon 68,508 4.2 16.8 4.5 968 New Rochelle 92,596 3.1 13.7 4.0 929 New York 1,812,533 5.3 26.6 5.7 1,828 Newark 34,207 3.6 15.1 3.3 820 Newburgh 74,539 4.2 15.9 4.2 1,043 Newfane 14,446 4.0 14.0 3.1 848 Niagara Falls 47,098 5.2 20.2 4.3 1,079 North Tarrytown 84,804 3.1 12.5 3.3 780 North Tonawanda 51,399 2.6 12.0 2.8 677 Norwich 25,793 3.1 16.0 3.4 1,065 Nyack 163,923 3.3 13.1 3.9 791 Oceanside 181,163 3.0 10.9 2.8 668 Ogdensburg 30,432 3.7 15.8 3.6 962 Olean 64,927 3.4 12.7 3.1 820 Oneida 39,254 3.5 17.6 3.7 1,079 Oneonta 45,364 2.9 14.7 2.8 1,059 Oswego 45,067 3.8 14.0 3.0 843 Patchogue 180,306 3.0 12.4 3.6 722 Peekskill 64,274 2.4 10.3 2.7 657 Penn Yan 21,208 3.5 15.4 3.5 867 Plainview 71,747 3.2 11.7 3.0 829 Plattsburgh 93,551 4.2 15.8 3.6 967 Port Chester 78,825 3.4 13.3 3.6 867 Port Jefferson 205,525 2.9 12.6 3.5 747 Port Jervis 41,762 3.6 12.9 3.6 827 Potsdam 47,311 3.0 13.1 3.0 829 Poughkeepsie 223,296 3.5 12.6 3.3 823 Rhinebeck 20,350 2.9 12.6 3.0 662 Riverhead 45,046 3.8 14.2 4.0 928 Rochester 749,139 2.9 16.1 3.5 975 Rockville Centre 109,692 3.6 13.4 3.4 818 Rome 74,756 2.6 12.0 2.8 744

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 28,941 3.7 14.3 3.3 1,004 Saratoga Springs 74,178 2.7 11.9 2.8 705 Schenectady 222,565 2.8 12.6 3.0 781 Seaford 21,644 3.0 11.7 3.0 741 Sidney 21,082 3.4 15.4 3.5 1,004 Smithtown 193,056 3.4 11.9 3.2 777 Sodus 25,909 3.1 12.9 2.9 735 Southampton 50,342 4.0 15.5 4.1 998 Springville 27,533 3.0 13.7 2.9 716 Star Lake 4,237 7.0 23.1 5.3 1,301 Staten Island 378,977 3.7 16.0 3.6 1,077 Stony Brook 29,722 2.8 13.4 4.0 840 Suffern 104,075 3.2 12.3 3.8 762 Syosset 42,890 3.1 12.3 3.3 855 Syracuse 529,861 2.7 13.6 3.4 900 Ticonderoga 11,018 5.1 19.6 4.7 1,237 Troy 162,165 3.8 15.2 3.8 801 Utica 211,650 3.1 14.0 3.5 876 Valley Stream 139,919 3.0 11.4 3.0 711 Walton 8,736 4.1 22.9 5.3 1,216 Warsaw 29,527 8.0 21.1 4.7 1,202 Warwick 24,718 3.1 11.9 3.2 768 Watertown 94,139 3.4 12.0 2.8 837 Wellsville 30,633 3.9 15.1 3.9 963 West Islip 193,419 2.8 10.9 3.2 617 Westfield 13,435 3.4 14.4 3.5 899 White Plains 136,328 4.0 15.9 5.0 1,042 Yonkers 155,725 4.0 16.3 3.8 968 Pennsylvania Abington 121,478 2.9 15.1 3.9 1,023 Aliquippa 39,782 4.7 20.4 4.6 1,312 Allentown 309,670 2.9 13.5 4.0 926 Altoona 122,103 3.0 14.3 3.1 1,150 Ashland 11,324 4.0 16.3 3.7 1,266 Beaver 112,887 3.9 17.1 4.4 1,097 Berwick 31,816 5.7 18.5 4.8 1,291 Bethlehem 131,579 3.2 13.4 3.7 954 Bloomsburg 39,124 3.6 13.6 3.5 987 Braddock 18,060 4.6 16.8 4.6 1,299 Bradford 31,010 4.0 16.2 4.0 1,157 Bristol 49,546 4.0 18.2 5.4 1,146 Brookville 23,147 3.9 18.3 4.9 1,258 Brownsville 22,037 4.0 16.2 4.1 1,204 Bryn Mawr 124,022 2.5 13.5 4.0 955 Butler 76,842 3.5 15.3 3.9 1,031 Camp Hill 146,253 2.8 12.2 3.0 841 Canonsburg 35,885 2.8 12.9 3.4 935 Carbondale 26,834 3.2 13.5 3.4 869 Carlisle 84,070 2.7 9.8 2.5 662 Chambersburg 95,380 2.6 11.4 2.4 875 Clarion 32,048 4.0 14.6 3.3 1,150 Clearfield 42,430 3.3 18.7 5.2 1,315 Coaldale 25,548 4.6 18.4 4.7 1,304 Coatesville 62,547 2.9 15.8 4.0 979 Connellsville 33,141 3.9 15.2 4.3 1,032 Corry 19,138 5.6 15.5 4.1 1,254 Coudersport 17,492 3.6 17.2 3.7 1,123 Danville 43,388 3.8 18.4 4.8 1,534 Darby 96,231 3.9 16.2 4.1 1,235 Doylestown 87,671 2.5 12.8 3.1 811 Drexel Hill 118,023 3.2 13.4 3.9 978 Dubois 43,590 3.6 18.6 4.7 1,164 East Stroudsburg 94,194 2.9 12.6 3.9 926 Easton 113,412 3.2 13.4 3.6 914 Ellwood City 25,848 3.9 14.7 3.9 1,104 Ephrata 53,424 2.6 11.2 2.6 757 Erie 261,279 3.6 13.3 3.7 1,088 Everett 33,088 3.0 13.0 3.2 916 Franklin 57,411 5.1 14.5 3.1 1,228 Gettysburg 46,660 2.5 12.5 3.1 963 Greensburg 79,056 4.4 18.9 5.1 1,345 Greenville 47,961 3.5 14.5 3.8 1,153 Grove City 33,561 3.2 11.6 3.2 936 Hanover 62,644 2.5 10.9 2.6 774 Harrisburg 242,452 3.2 15.1 3.9 1,150 Hazleton 75,361 3.9 14.6 3.8 1,028 Hershey 20,756 2.8 14.8 4.8 1,294 Honesdale 32,549 3.2 14.1 3.7 970 Huntingdon 45,166 3.1 11.8 3.0 917 Indiana 64,609 3.1 15.3 3.6 1,167 Jeannette 77,271 3.9 14.4 3.8 1,049 Jersey Shore 16,178 3.7 13.1 2.7 905 Johnstown 151,021 4.1 20.5 5.3 1,518 Kane 10,176 5.3 17.4 4.7 1,200 Kingston 36,818 3.9 14.8 3.8 1,068 Kittanning 44,530 3.7 15.0 4.4 1,108 Lancaster 372,386 2.6 11.4 2.7 791 Langhorne 237,112 3.1 13.9 3.7 941 Lansdale 80,730 2.6 11.9 3.3 769 Latrobe 75,759 3.2 16.4 3.9 1,106 Lebanon 119,133 2.2 10.7 2.7 762 Lehighton 27,820 3.9 16.5 4.5 989 Lewisburg 72,802 2.9 12.6 3.5 949 Lewistown 66,249 3.4 14.7 3.4 1,010

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 32,753 5.7 16.2 3.8 1,257 Mcconnellsburg 13,194 3.5 15.1 2.9 1,022 Mckees Rocks 25,092 3.8 17.8 4.7 1,371 Mckeesport 79,781 4.1 17.8 4.2 1,216 Meadville 66,668 4.3 13.4 3.2 1,034 Media 50,667 3.6 16.4 4.3 1,065 Meyersdale 10,594 3.6 12.2 2.6 849 Monongahela 68,888 4.1 17.4 4.1 1,227 Monroeville 96,344 3.7 14.7 4.3 1,214 Montrose 8,938 4.1 15.9 4.1 1,059 Mount Pleasant 42,286 4.5 18.5 4.8 1,233 Muncy 27,890 3.1 13.7 3.1 933 Natrona Heights 92,458 3.5 14.2 3.8 1,005 New Castle 80,724 4.1 19.3 4.9 1,337 New Kensington 41,922 3.8 15.2 4.0 1,069 Norristown 179,653 3.3 13.3 3.6 949 Palmerton 17,584 3.4 14.7 4.2 905 Paoli 49,988 2.3 11.6 3.0 817 Peckville 6,252 2.4 8.9 2.3 614 Philadelphia 1,783,172 4.5 21.6 5.5 1,648 Philipsburg 14,380 2.8 11.8 3.7 825 Phoenixville 59,102 2.6 11.1 2.9 761 Pittsburgh 1,120,130 4.0 19.5 5.0 1,540 Pottstown 81,454 2.7 11.7 3.2 749 Pottsville 117,182 3.7 13.7 3.4 1,039 Punxsutawney 21,759 3.2 17.0 4.7 1,204 Quakertown 35,284 2.5 11.2 2.6 760 Reading 300,097 2.6 12.2 2.8 811 Renovo 3,848 5.5 25.5 4.4 1,500 Ridgway 10,769 5.1 19.9 4.8 1,416 Ridley Park 94,485 3.4 14.4 3.6 1,046 Roaring Spring 23,081 2.7 11.1 3.0 808 Sayre 63,983 3.2 12.5 3.6 932 Scranton 222,667 3.3 13.8 3.6 1,056 Sellersville 89,066 2.5 12.7 3.1 766 Sewickley 79,854 3.1 16.6 4.3 1,193 Shamokin 21,106 3.9 19.0 4.8 1,557 Sharon 53,793 4.2 19.0 4.8 1,419 Somerset 39,440 3.2 17.5 4.5 1,334 Spangler 24,428 2.8 15.3 3.7 1,198 St Marys 25,270 4.1 16.8 3.6 1,040 State College 110,236 2.1 9.3 2.5 696 Sunbury 48,047 3.8 15.0 3.6 1,113 Susquehanna 12,155 4.5 19.1 4.0 1,184 Titusville 24,122 5.6 16.9 4.4 1,259 Towanda 20,627 3.3 13.5 4.4 952 Tunkhannock 22,387 3.1 13.0 4.2 887 Tyrone 17,259 3.4 11.9 3.3 1,039 Union City 8,890 3.9 15.0 3.5 987 Uniontown 82,693 3.6 15.6 4.1 1,190 Upland 116,969 4.7 21.2 4.8 1,396 Warminster 37,480 2.9 11.0 2.9 802 Warren 38,240 3.3 14.1 4.0 967 Washington 87,504 3.3 14.7 3.6 1,070 Waynesboro 45,794 2.5 11.5 2.9 890 Waynesburg 32,933 4.0 17.5 4.8 1,480 Wellsboro 39,437 3.4 13.5 2.6 868 West Chester 141,812 2.5 12.6 3.2 867 West Grove 41,564 2.6 14.2 3.4 888 Wilkes-Barre 221,488 3.7 13.5 3.4 958 Williamsport 88,829 3.2 14.0 3.0 953 Windber 16,485 3.8 17.7 4.6 1,240 York 278,302 2.4 13.0 3.0 904

PART THREE The Medicare Program in the Middle Atlantic States

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 1992-93, 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.

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 1992-93, 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 1993. 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 3.10-3.13) is the 1993 enrollee population. The estimates therefore do not include population gain or loss that may have occurred since 1993.

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 (1992-93) 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.

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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 (1992-93) Reimbursements for professional and laboratory services varied by a factor of more than 2.9. Each point represents one hospital service area.

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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 (1992-93) 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.

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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 (1992-93) Price adjusted Medicare reimbursements for outpatient services varied by a factor of more than 4.2. Each point represents one hospital service area.

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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.

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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.

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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 1992-93, 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.

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

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 (1992-93) 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 1992-93 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 1992-93 had been attained in Pittsburgh, $772 million less would have been spent for Medicare enrollees in Pittsburgh.

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. (1992-93) 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 1992-93 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.

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 (1992-93) 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 1992-93 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 1992-93 had been attained in Philadelphia, $297 million less would have been spent for Philadelphia residents.

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. (1992-93) 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 1992-93 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 1992-93 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.

84 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Benchmarking: AAPCC Figure 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. 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.

THE MEDICARE PROGRAM 85 Benchmarking: AAPCC Figure 3.11. 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.

86 THE DARTMOUTH ATLAS OF HEALTH CARE: THE MIDDLE ATLANTIC STATES Benchmarking: AAPCC Figure 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. 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.

THE MEDICARE PROGRAM 87 Benchmarking: AAPCC Figure 3.13. 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.

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, 1993. 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 1992-93. 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.

THE MEDICARE PROGRAM 89 TABLE 3 Medicare Reimbursements per Enrollee by Program Components (1992-93) 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 2,076 312 5,960 5,380 Bayonne 61,444 21,514 3,973 1,188 2,364 249 6,064 5,109 Belleville 61,365 19,195 3,456 1,080 1,727 217 6,217 5,051 Bridgeton 87,961 22,633 3,965 1,101 2,208 342 5,723 5,571 Camden 509,238 123,471 3,892 1,140 2,144 229 6,181 5,641 Cape May Court House 70,984 28,537 4,812 1,410 2,192 358 5,968 5,387 Denville 104,485 20,986 3,422 1,027 1,757 270 5,506 4,473 Dover 139,426 22,673 3,619 1,037 2,020 339 5,468 4,442 Edison 175,032 43,733 3,279 1,056 1,916 196 5,990 4,884 Elizabeth 189,124 47,545 2,876 898 2,007 208 5,797 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 1,611 198 5,562 4,513 Flemington 96,472 18,475 3,015 874 1,581 235 5,376 4,383 Freehold 98,712 24,398 3,221 1,017 1,951 319 5,678 5,012 Hackensack 137,814 42,943 2,537 898 1,662 214 5,562 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 1,998 298 6,064 5,109 Holmdel 111,073 22,730 3,758 1,103 2,071 274 5,692 5,025 Irvington 60,986 9,590 (3,781) 1,096 2,190 (190) 6,217 5,051 Jersey City 228,537 42,100 3,300 990 2,225 199 6,064 5,109 Kearny 64,085 18,214 3,160 954 1,905 (171) 5,905 4,976 Lakewood 125,880 43,266 3,726 1,157 1,844 360 5,299 4,678 Livingston 107,839 33,712 3,205 1,029 1,706 228 6,217 5,051 Long Branch 78,311 21,051 3,695 1,092 2,074 315 5,692 5,025 Manahawkin 57,947 23,190 3,191 996 1,834 267 5,260 4,643 Montclair 150,696 47,015 3,243 1,062 1,636 272 6,217 5,051 Morristown 155,945 39,693 3,156 961 1,547 266 5,395 4,383 Mount Holly 161,533 33,716 3,451 980 1,960 288 5,804 5,297 Neptune 116,432 34,317 3,479 1,070 1,961 255 5,692 5,025 New Brunswick 282,900 54,119 3,217 947 1,903 195 5,837 4,759 Newark 317,309 52,423 4,317 1,169 2,368 345 6,217 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 1,857 213 6,064 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 2,809 930 1,671 202 5,519 4,479 Paterson 168,959 33,481 3,364 1,056 1,873 208 5,503 4,466 Price-Adjusted AAPCC (1996)

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 1,976 261 5,951 4,835 Plainfield 126,986 29,525 3,013 978 1,628 164 5,480 4,452 Point Pleasant 107,468 40,518 3,287 1,010 1,807 278 5,318 4,695 Pompton Plains 105,870 22,020 3,566 1,094 1,782 221 5,497 4,466 Princeton 146,406 38,656 2,830 906 1,637 210 6,078 5,237 Rahway 74,247 22,530 2,935 945 1,937 236 5,869 4,768 Red Bank 114,186 29,504 3,418 1,070 1,788 207 5,692 5,025 Ridgewood 187,639 52,087 2,731 929 1,480 253 5,554 4,507 Riverside 48,882 13,705 3,526 942 1,988 (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 1,885 316 5,963 5,383 Somerville 131,320 29,158 3,315 954 1,613 214 5,069 4,132 South Amboy 56,171 13,416 4,156 1,081 2,148 (221) 5,990 4,884 Stratford 161,635 31,458 3,659 995 2,416 219 6,232 5,688 Summit 152,400 47,042 3,239 1,004 1,591 259 5,774 4,691 Sussex 44,552 7,495 (3,156) 896 1,665 (242) 5,168 4,199 Teaneck 144,635 44,413 3,036 985 1,668 254 5,562 4,513 Toms River 181,765 103,579 3,564 1,119 1,766 321 5,260 4,643 Trenton 277,421 75,341 3,721 1,053 2,211 372 6,265 5,398 Union 89,774 33,308 3,318 982 1,898 199 5,797 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 1,612 203 5,489 4,454 Westwood 100,870 26,635 2,757 943 1,514 262 5,562 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 2,085 233 6,212 5,670 New York Albany 301,861 83,261 2,771 875 1,399 209 4,562 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 1,748 180 6,755 5,201 Amsterdam 56,147 21,139 2,930 772 1,588 276 4,141 3,995 Auburn 80,425 22,826 2,991 809 1,755 245 4,601 4,680 Batavia 67,447 17,078 2,671 721 1,710 (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 1,647 205 6,433 4,953 Bethpage 130,254 30,961 3,333 1,154 1,782 180 6,789 5,227 Binghamton 263,453 75,654 2,787 757 1,604 263 4,279 4,418 Brockport 38,437 5,831 (2,743) (708) 1,748 (294) 4,626 4,515 Bronx 1,118,765 192,840 4,043 1,039 2,517 287 8,804 6,906 Bronxville 63,148 24,296 3,156 1,083 1,678 204 6,626 5,197 Brooklyn 2,184,026 419,498 3,837 1,219 2,288 230 8,437 6,618 Buffalo 796,974 235,096 2,963 862 1,612 222 4,717 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 2,505 673 1,510 (215) 3,855 3,762 Price-Adjusted AAPCC (1996)

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 1,713 282 4,376 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 2,819 749 1,685 (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 3,475 823 1,729 (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 2,720 855 1,824 (320) 3,938 4,469 East Meadow 105,921 25,430 3,183 1,026 2,069 150 6,905 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 3,152 820 1,755 332 4,192 4,730 Far Rockaway 134,206 37,353 5,273 1,780 2,805 242 7,551 5,923 Flushing 855,174 220,286 3,656 1,152 2,002 213 7,823 6,136 Fulton 32,700 8,408 (3,696) 1,037 1,815 (278) 4,350 4,425 Geneva 48,828 14,636 2,932 786 1,579 (358) 4,183 4,082 Glen Cove 72,566 20,844 3,503 997 1,834 201 6,905 5,316 Glens Falls 129,549 33,927 2,764 823 1,629 269 4,217 4,412 Gloversville 46,862 15,906 3,366 916 1,730 (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 2,646 965 1,462 134 6,433 4,953 Irving 22,699 6,371 (3,854) (1,061) 1,623 (286) 4,494 4,570 Ithaca 94,468 16,963 3,452 855 1,600 (263) 4,101 4,482 Jamaica 637,762 136,824 3,393 944 1,981 196 7,823 6,136 Jamestown 82,572 26,055 3,126 769 1,593 272 3,955 4,488 Kenmore 96,518 29,980 2,774 805 1,546 255 4,717 4,797 Kingston 123,117 33,157 3,484 989 1,994 193 5,102 5,576 Lackawanna 35,685 10,961 (2,554) 770 1,519 (216) 4,717 4,797 Lewiston 57,798 18,960 2,581 761 1,625 272 4,716 4,796 Little Falls 21,245 7,236 (3,771) 845 1,752 (264) 4,053 4,335 Lockport 54,408 14,052 2,686 776 1,856 (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 3,534 998 1,959 140 7,823 6,136 Lowville 20,087 5,428 (3,929) (830) 1,389 (381) 3,684 4,026 Price-Adjusted AAPCC (1996)

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 1,665 205 7,251 5,583 Manhattan 1,812,533 414,633 4,003 1,150 2,228 261 8,542 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 3,231 874 1,909 284 5,489 5,025 Mineola 177,792 56,078 3,220 1,013 1,755 179 6,905 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 1,593 165 6,626 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 1,822 151 6,626 5,197 Newark 34,207 9,463 (2,672) 712 1,655 (263) 3,913 3,819 Newburgh 74,539 19,743 3,396 964 1,888 151 5,418 4,960 Newfane 14,446 3,891 (3,681) (1,010) 1,910 (298) 4,716 4,796 Niagara Falls 47,098 16,204 3,701 920 1,886 (488) 4,716 4,796 North Tarrytown 84,804 22,285 2,982 972 1,605 220 6,626 5,197 North Tonawanda 51,399 12,409 2,929 917 1,703 (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 1,798 225 7,024 5,509 Oceanside 181,163 44,883 2,925 1,070 1,644 165 6,905 5,316 Ogdensburg 30,432 8,037 (3,153) 812 1,591 (605) 4,129 4,513 Olean 64,927 19,274 3,006 862 1,796 204 4,245 4,639 Oneida 39,254 11,216 (3,197) 810 1,783 (283) 4,185 4,256 Oneonta 45,364 12,798 2,971 641 1,905 (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 1,898 176 6,433 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 1,708 168 6,905 5,316 Plattsburgh 93,551 18,818 3,911 949 1,987 496 4,581 5,007 Port Chester 78,825 22,908 3,052 982 1,700 221 6,626 5,197 Port Jefferson 205,525 37,118 3,378 1,063 1,793 236 6,433 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 2,801 877 1,657 203 5,104 4,524 Rhinebeck 20,350 6,027 (2,279) (852) 1,356 (189) 5,104 4,524 Riverhead 45,046 16,219 3,121 956 1,682 (235) 6,433 4,953 Rochester 749,139 159,607 3,047 741 1,689 262 4,932 4,813 Rockville Centre 109,692 25,617 3,364 1,112 1,686 232 6,905 5,316 Rome 74,756 18,108 2,915 894 1,797 (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 2,387 827 1,537 (219) 4,438 4,280 Schenectady 222,565 61,491 2,837 838 1,417 257 4,288 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)

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 1,984 250 6,433 4,953 Sodus 25,909 6,213 (3,035) (800) 1,791 (247) 3,913 3,819 Southampton 50,342 20,188 2,974 934 1,555 228 6,433 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 2,534 326 9,102 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 1,831 212 6,965 5,463 Syosset 42,890 11,624 (3,240) 1,264 1,740 (209) 6,905 5,316 Syracuse 529,861 131,757 3,050 918 1,626 226 4,398 4,473 Ticonderoga 11,018 3,643 (2,774) (588) 1,889 (450) 4,267 4,663 Troy 162,165 45,261 3,203 988 1,696 260 4,658 4,493 Utica 211,650 70,132 2,892 898 1,653 242 4,095 4,380 Valley Stream 139,919 40,979 2,968 1,096 1,660 119 7,002 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 2,839 750 1,381 285 3,732 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 1,646 204 6,433 4,953 Westfield 13,435 4,018 (2,538) (609) 1,701 (301) 3,938 4,469 White Plains 136,328 39,141 3,156 979 1,653 261 6,626 5,197 Yonkers 155,725 41,676 3,652 1,131 2,074 223 6,626 5,197 Pennsylvania Abington 121,478 37,057 3,767 1,147 1,870 329 5,863 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 1,905 285 5,605 5,581 Altoona 122,103 39,865 4,274 867 1,856 364 5,008 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 2,042 388 5,845 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 1,955 270 5,833 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 1,659 371 6,264 5,717 Butler 76,842 23,575 4,726 1,028 1,901 402 5,597 5,686 Camp Hill 146,253 40,672 3,532 979 1,691 274 4,478 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 3,254 915 1,477 382 4,601 4,743 Chambersburg 95,380 26,483 3,291 780 1,695 321 4,004 4,584 Clarion 32,048 8,121 (5,020) 971 2,425 (546) 5,797 6,638 Price-Adjusted AAPCC (1996)

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 3,926 904 2,041 (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 4,042 864 1,855 (694) 4,752 5,441 Darby 96,231 24,589 5,077 1,321 2,599 425 7,270 6,635 Doylestown 87,671 20,479 3,702 1,133 1,680 360 6,430 5,868 Drexel Hill 118,023 37,923 3,786 1,243 1,970 352 6,564 5,991 Dubois 43,590 13,975 3,642 817 1,819 (447) 5,401 6,184 East Stroudsburg 94,194 26,925 4,633 1,312 1,937 247 6,110 6,996 Easton 113,412 35,892 4,051 1,127 2,230 355 5,923 5,897 Ellwood City 25,848 8,658 (4,541) 1,008 2,354 (419) 5,726 6,556 Ephrata 53,424 13,302 3,493 985 1,480 (336) 4,094 4,311 Erie 261,279 74,193 3,514 1,055 1,696 297 4,764 5,362 Everett 33,088 10,719 (4,750) 947 1,938 (589) 4,873 5,580 Franklin 57,411 18,658 4,433 982 2,254 483 5,205 5,960 Gettysburg 46,660 13,133 3,460 855 1,753 (394) 4,186 4,793 Greensburg 79,056 29,019 4,540 1,186 2,353 392 6,268 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 2,927 851 1,442 263 4,176 4,485 Harrisburg 242,452 67,368 4,237 1,001 1,827 347 5,370 5,536 Hazleton 75,361 30,867 4,796 1,369 1,921 482 5,312 5,787 Hershey 20,756 5,724 (4,929) (901) 1,828 (516) 5,386 5,552 Honesdale 32,549 12,720 3,144 829 1,728 (218) 4,696 5,376 Huntingdon 45,166 12,634 3,601 802 1,765 (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 2,423 352 6,268 6,367 Jersey Shore 16,178 4,318 (2,965) (806) 1,736 (424) 4,694 5,141 Johnstown 151,021 56,774 4,567 972 2,595 453 5,912 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 4,518 970 2,121 (574) 5,460 6,252 Lancaster 372,386 100,869 3,000 933 1,458 379 4,102 4,319 Langhorne 237,112 49,700 3,921 1,340 2,168 302 6,430 5,868 Lansdale 80,730 19,056 3,765 1,168 1,596 312 5,867 5,355 Latrobe 75,759 25,531 4,650 1,088 2,337 437 6,229 6,328 Lebanon 119,133 35,713 4,895 900 1,504 263 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 3,204 871 1,712 425 4,380 5,015 Lewistown 66,249 20,592 3,908 981 2,039 448 5,225 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)

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 2,551 300 6,704 6,811 Meadville 66,668 20,987 3,741 1,016 1,915 365 4,874 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 2,334 284 6,198 6,297 Monroeville 96,344 31,190 5,122 1,437 2,358 355 6,547 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 1,970 408 6,177 6,275 New Castle 80,724 30,125 4,354 1,059 2,198 500 5,699 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 1,916 349 5,863 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 1,783,172 499,174 4,473 1,336 2,393 325 7,855 7,169 Philipsburg 14,380 4,699 (3,186) (744) 1,623 (260) 4,908 5,346 Phoenixville 59,102 14,954 3,401 964 1,622 (290) 5,774 5,270 Pittsburgh 1,120,130 379,312 4,854 1,271 2,257 372 6,657 6,763 Pottstown 81,454 22,064 2,915 863 1,532 209 5,491 5,012 Pottsville 117,182 46,192 3,983 1,097 1,879 339 5,070 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 3,206 930 1,500 275 4,672 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 2,256 242 6,564 5,991 Roaring Spring 23,081 6,543 (3,526) (782) 1,733 (450) 4,868 5,652 Sayre 63,983 18,029 3,794 779 1,757 (212) 3,953 4,526 Scranton 222,667 86,546 4,410 1,189 1,798 284 5,464 5,952 Sellersville 89,066 21,227 3,598 1,164 1,564 239 6,044 5,517 Sewickley 79,854 27,617 3,527 977 1,917 378 6,360 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 2,242 443 5,345 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 3,726 897 1,610 344 4,603 5,014 Sunbury 48,047 15,069 3,926 925 1,942 (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)

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 5,132 964 2,489 305 6,469 6,572 Upland 116,969 29,297 4,386 1,209 2,257 317 6,564 5,991 Warminster 37,480 6,960 (5,155) 1,373 2,203 (367) 6,430 5,868 Warren 38,240 12,413 3,781 937 1,703 (456) 4,231 4,844 Washington 87,504 28,604 4,804 1,160 2,243 330 6,139 6,237 Waynesboro 45,794 13,201 3,354 746 1,693 (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 3,058 745 1,649 (331) 3,938 4,509 West Chester 141,812 29,251 3,648 1,124 1,775 361 5,769 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 1,766 367 5,347 5,824 Williamsport 88,829 28,371 3,427 969 1,621 450 4,599 5,037 Windber 16,485 6,684 (3,727) (669) 2,126 (519) 5,390 6,318 York 278,302 75,264 2,952 801 1,492 277 4,211 4,523 Price-Adjusted AAPCC (1996)

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 1993. 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.

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.

THE PHYSICIAN WORKFORCE 99

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.

THE PHYSICIAN WORKFORCE 101

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.

THE PHYSICIAN WORKFORCE 103

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.

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.

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.

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.

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.

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.

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 1.14. (Weiner JP. Forecasting the Effects of Health Reform on U.S. Physician Workforce Requirement. JAMA. 1994;272:222-239)

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 154,316 179.0 54.2 123.7 Bayonne 61,444 207.5 74.7 132.2 Belleville 61,365 222.0 76.8 143.9 Bridgeton 87,961 147.2 52.9 93.1 Camden 509,238 242.1 86.7 154.3 Cape May Court House 70,984 211.1 72.0 137.4 Denville 104,485 221.4 76.2 144.3 Dover 139,426 176.6 62.6 113.7 Edison 175,032 235.4 83.4 150.8 Elizabeth 189,124 195.6 75.0 120.3 Elmer 36,897 114.9 41.0 73.5 Englewood 133,340 351.7 102.6 247.5 Flemington 96,472 188.3 76.6 109.9 Freehold 98,712 244.8 79.1 164.4 Hackensack 137,814 218.2 77.3 139.7 Hackettstown 40,212 161.6 48.9 112.4 Hammonton 23,068 231.3 74.3 156.5 Hoboken 103,043 198.6 75.1 122.3 Holmdel 111,073 199.5 73.2 125.8 Irvington 60,986 148.1 56.3 91.1 Jersey City 228,537 183.8 73.1 109.1 Kearny 64,085 183.4 66.9 115.9 Lakewood 125,880 182.0 59.4 121.5 Livingston 107,839 328.2 99.1 226.6 Long Branch 78,311 230.2 69.7 158.0 Manahawkin 57,947 194.1 61.7 131.6 Montclair 150,696 298.5 101.6 193.8 Morristown 155,945 258.2 83.4 173.7 Mount Holly 161,533 189.3 60.2 128.2 Neptune 116,432 207.5 76.9 129.3 New Brunswick 282,900 207.3 78.3 127.9 Newark 317,309 156.8 59.2 96.6 Newton 72,874 192.0 67.3 124.2 North Bergen 95,558 242.7 81.9 157.3 Orange 61,407 169.7 61.7 106.2 Paramus 25,085 340.1 114.3 222.4 Passaic 211,422 212.6 77.2 133.5 Paterson 168,959 175.3 68.7 105.9 Perth Amboy 46,666 137.0 46.9 89.5 Phillipsburg 66,046 179.3 67.4 111.1 Plainfield 126,986 233.0 80.0 151.5 Point Pleasant 107,468 190.4 58.6 130.7 Pompton Plains 105,870 142.8 55.3 87.1 Princeton 146,406 293.1 95.1 195.5 Rahway 74,247 206.4 83.1 122.7 Red Bank 114,186 226.5 69.1 156.3 Ridgewood 187,639 246.1 85.0 160.0 Riverside 48,882 206.2 87.9 117.5 Salem 50,562 192.9 70.6 121.8 Secaucus 14,061 199.2 76.3 122.0 Somers Point 62,423 254.9 80.5 173.7 Somerville 131,320 231.0 83.8 145.7 South Amboy 56,171 180.7 63.2 115.7 Stratford 161,635 172.4 63.9 107.6 Summit 152,400 327.8 99.3 227.3 Sussex 44,552 150.6 63.0 85.7 Teaneck 144,635 306.1 98.2 206.3 Toms River 181,765 219.1 68.4 150.0 Trenton 277,421 225.4 80.4 143.9 Union 89,774 327.0 112.4 213.6 Vineland 64,429 223.0 72.1 150.4 Wayne 89,417 230.3 80.6 148.8 Westwood 100,870 269.7 95.0 173.4 Willingboro 81,814 196.0 74.3 120.5 Woodbury 119,186 172.8 69.2 102.6 New York Albany 301,861 223.2 71.6 150.2 Alexandria Bay 9,786 138.5 47.4 90.9 Amityville 119,243 250.8 84.7 164.1 Amsterdam 56,147 155.4 50.4 104.5 Auburn 80,425 148.8 49.6 98.9 Batavia 67,447 137.1 46.3 90.3 Bath 23,737 175.0 89.3 81.8 Bay Shore 173,014 234.6 82.5 150.6 Bethpage 130,254 255.2 88.8 164.9 Binghamton 263,453 167.2 55.1 111.3 Brockport 38,437 114.7 41.2 71.7

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 1,118,765 197.0 70.9 124.8 Bronxville 63,148 343.5 105.8 236.3 Brooklyn 2,184,026 219.1 78.1 139.8 Buffalo 796,974 203.0 66.2 135.7 Callicoon 3,588 (133.5) (46.8) (86.3) Cambridge 15,274 188.7 70.2 117.8 Canandaigua 59,572 184.8 77.8 105.4 Carmel 72,211 231.2 75.5 154.3 Carthage 14,945 139.5 39.2 95.7 Catskill 63,896 201.2 65.5 134.9 Clifton Springs 25,153 152.6 57.3 94.8 Cobleskill 23,880 189.0 70.4 117.6 Cold Spring 4,904 (286.6) (111.8) (174.0) Cooperstown 37,599 172.5 56.2 114.0 Corning 44,951 158.1 57.6 100.1 Cornwall 63,589 137.0 45.5 89.8 Cortland 59,359 135.4 64.4 69.4 Cuba 9,277 136.4 49.0 86.5 Dansville 36,386 147.6 64.5 82.5 Dobbs Ferry 15,425 324.0 104.5 215.8 Dunkirk 39,633 139.4 49.8 89.3 East Meadow 105,921 262.4 90.9 170.2 Elizabethtown 6,009 174.7 79.6 94.0 Ellenville 11,280 199.1 70.8 127.4 Elmira 99,784 171.2 53.5 116.8 Far Rockaway 134,206 412.2 142.2 268.2 Flushing 855,174 306.4 111.3 193.0 Fulton 32,700 139.5 43.2 93.7 Geneva 48,828 181.4 62.8 118.3 Glen Cove 72,566 312.6 95.1 216.8 Glens Falls 129,549 157.6 56.5 100.1 Gloversville 46,862 176.2 69.2 106.6 Goshen 62,879 177.8 56.8 119.7 Gouverneur 11,757 146.8 41.9 104.4 Gowanda 18,266 145.4 65.7 79.3 Greenport 16,920 279.0 86.3 190.9 Hamilton 27,218 144.6 52.7 91.5 Harris 50,165 233.8 75.3 157.8 Hornell 26,700 166.2 55.6 110.2 Huntington 188,851 302.2 99.2 200.9 Irving 22,699 135.5 52.2 82.9 Ithaca 94,468 162.7 62.2 100.3 Jamaica 637,762 226.4 85.8 139.0 Jamestown 82,572 137.8 39.0 96.7 Kenmore 96,518 151.9 47.7 103.0 Kingston 123,117 205.3 78.3 125.4 Lackawanna 35,685 125.7 44.0 81.1 Lewiston 57,798 155.5 49.2 104.9 Little Falls 21,245 118.9 41.7 76.8 Lockport 54,408 154.8 62.7 91.8 Long Beach 50,754 262.6 92.8 166.2 Long Island City 142,487 250.5 94.2 154.5 Lowville 20,087 166.3 66.9 98.9 Malone 31,011 182.3 74.4 104.3 Manhasset 166,274 249.9 73.9 174.3 Margaretville 9,755 160.5 55.8 103.9 Massena 18,095 190.9 67.2 122.4 Medina 33,492 176.4 67.1 108.3 Middletown 90,000 231.7 68.8 162.3 Mineola 177,792 354.9 113.5 239.7 Montour Falls 12,017 168.2 74.8 93.0 Mount Kisco 125,577 363.3 101.5 260.2 Mount Vernon 68,508 288.3 94.3 193.4 New Rochelle 92,596 409.6 117.0 291.9 New York 1,812,533 327.8 100.8 225.0 Newark 34,207 168.0 60.2 107.5 Newburgh 74,539 239.9 74.1 164.4 Newfane 14,446 112.9 49.7 62.8 Niagara Falls 47,098 193.7 56.4 136.3 North Tarrytown 84,804 374.4 123.0 250.6 North Tonawanda 51,399 105.3 37.6 67.3 Norwich 25,793 154.5 51.6 102.4 Nyack 163,923 318.2 108.2 208.2 Oceanside 181,163 225.2 81.5 142.5 Ogdensburg 30,432 155.5 36.5 118.6 Olean 64,927 172.3 66.0 104.9 Oneida 39,254 166.1 64.2 101.4 Oneonta 45,364 159.2 57.2 101.1 Oswego 45,067 129.3 43.3 85.6 Patchogue 180,306 174.5 63.6 110.1 Peekskill 64,274 213.9 63.5 149.9 Penn Yan 21,208 143.9 39.7 103.6 Plainview 71,747 318.0 114.2 202.3 Plattsburgh 93,551 167.9 60.8 105.1 Port Chester 78,825 375.9 111.7 262.4 Port Jefferson 205,525 222.1 71.0 149.6 Port Jervis 41,762 171.3 60.5 110.5 Potsdam 47,311 145.2 48.2 93.2 Poughkeepsie 223,296 221.9 65.5 155.8 Rhinebeck 20,350 233.3 90.6 142.1 Riverhead 45,046 234.5 67.8 164.1 Rochester 749,139 203.7 76.8 125.7 Rockville Centre 109,692 227.4 76.5 149.9 Rome 74,756 179.0 73.6 105.0

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 28,941 200.0 83.3 116.1 Saratoga Springs 74,178 190.3 67.2 121.6 Schenectady 222,565 187.8 59.3 127.2 Seaford 21,644 198.6 66.2 131.2 Sidney 21,082 155.5 48.8 106.3 Smithtown 193,056 281.0 94.6 184.8 Sodus 25,909 128.2 46.5 81.3 Southampton 50,342 310.7 91.1 216.6 Springville 27,533 146.2 61.3 84.3 Star Lake 4,237 (228.8) (92.2) (135.2) Staten Island 378,977 243.6 87.9 154.8 Stony Brook 29,722 198.6 63.9 133.0 Suffern 104,075 237.8 67.5 169.7 Syosset 42,890 355.9 131.9 222.2 Syracuse 529,861 179.4 59.1 119.3 Ticonderoga 11,018 207.3 83.8 122.5 Troy 162,165 163.4 55.7 106.8 Utica 211,650 192.6 58.8 133.1 Valley Stream 139,919 262.8 93.4 167.6 Walton 8,736 137.0 42.4 93.9 Warsaw 29,527 124.0 40.3 80.9 Warwick 24,718 156.7 56.1 100.1 Watertown 94,139 127.1 40.8 85.8 Wellsville 30,633 139.8 55.0 84.4 West Islip 193,419 172.2 62.7 108.2 Westfield 13,435 174.2 76.7 97.0 White Plains 136,328 389.2 113.5 273.9 Yonkers 155,725 272.9 93.9 176.4 Pennsylvania Abington 121,478 217.8 65.9 151.2 Aliquippa 39,782 180.8 60.2 119.8 Allentown 309,670 196.5 73.1 122.7 Altoona 122,103 155.3 52.6 102.6 Ashland 11,324 133.1 41.3 91.4 Beaver 112,887 154.1 49.9 103.8 Berwick 31,816 173.3 66.4 106.4 Bethlehem 131,579 172.3 56.8 113.8 Bloomsburg 39,124 148.5 62.5 85.5 Braddock 18,060 139.0 43.4 94.6 Bradford 31,010 139.1 48.3 90.5 Bristol 49,546 244.2 104.2 139.0 Brookville 23,147 137.9 48.3 89.4 Brownsville 22,037 164.4 50.1 113.5 Bryn Mawr 124,022 413.6 136.1 275.8 Butler 76,842 153.4 50.1 103.1 Camp Hill 146,253 205.6 78.1 127.3 Canonsburg 35,885 162.1 59.0 101.5 Carbondale 26,834 162.2 55.3 106.6 Carlisle 84,070 137.8 56.4 81.3 Chambersburg 95,380 142.3 51.1 90.1 Clarion 32,048 140.8 62.0 78.6 Clearfield 42,430 164.4 67.9 96.3 Coaldale 25,548 192.9 76.3 116.2 Coatesville 62,547 179.0 58.6 120.1 Connellsville 33,141 146.2 56.1 89.8 Corry 19,138 139.8 38.9 100.8 Coudersport 17,492 137.5 56.4 80.8 Danville 43,388 201.7 61.2 139.3 Darby 96,231 178.7 62.9 113.8 Doylestown 87,671 214.0 68.9 144.8 Drexel Hill 118,023 237.0 86.6 148.4 Dubois 43,590 144.8 41.0 103.6 East Stroudsburg 94,194 173.0 54.9 117.7 Easton 113,412 181.1 64.0 115.2 Ellwood City 25,848 94.0 33.1 60.6 Ephrata 53,424 126.2 53.2 72.8 Erie 261,279 164.6 59.1 105.4 Everett 33,088 133.1 55.5 77.4 Franklin 57,411 156.4 57.7 98.6 Gettysburg 46,660 150.2 65.1 84.8 Greensburg 79,056 194.6 67.6 125.7 Greenville 47,961 120.0 37.1 81.8 Grove City 33,561 120.4 41.1 79.0 Hanover 62,644 135.1 58.8 76.2 Harrisburg 242,452 172.2 72.7 99.1 Hazleton 75,361 179.0 66.6 112.0 Hershey 20,756 164.7 49.8 114.1 Honesdale 32,549 165.2 65.2 99.6 Huntingdon 45,166 158.5 57.7 100.6 Indiana 64,609 147.5 56.1 91.1 Jeannette 77,271 142.4 54.8 86.1 Jersey Shore 16,178 126.7 46.6 79.7 Johnstown 151,021 171.2 63.4 106.4 Kane 10,176 161.8 58.0 103.3 Kingston 36,818 251.1 87.6 163.1 Kittanning 44,530 128.6 50.2 78.2 Lancaster 372,386 160.4 64.0 95.9 Langhorne 237,112 238.0 90.2 146.7 Lansdale 80,730 212.0 76.2 135.3 Latrobe 75,759 163.3 68.4 94.5 Lebanon 119,133 181.2 61.5 117.2 Lehighton 27,820 148.7 54.6 93.8 Lewisburg 72,802 155.5 58.2 95.9 Lewistown 66,249 159.9 63.1 96.5

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 32,753 167.2 68.8 98.0 Mcconnellsburg 13,194 103.9 35.0 68.5 Mckees Rocks 25,092 155.0 56.2 98.2 Mckeesport 79,781 175.3 57.2 116.6 Meadville 66,668 152.5 52.1 100.2 Media 50,667 301.5 98.3 201.5 Meyersdale 10,594 122.4 55.8 65.9 Monongahela 68,888 185.4 58.0 124.5 Monroeville 96,344 195.8 67.7 126.1 Montrose 8,938 179.7 78.3 101.0 Mount Pleasant 42,286 159.4 58.7 100.3 Muncy 27,890 147.0 56.1 90.4 Natrona Heights 92,458 146.5 48.9 97.0 New Castle 80,724 139.0 43.6 95.1 New Kensington 41,922 170.1 55.5 112.9 Norristown 179,653 279.1 102.3 175.1 Palmerton 17,584 145.3 57.7 87.2 Paoli 49,988 256.4 77.7 177.5 Peckville 6,252 115.7 43.5 71.8 Philadelphia 1,783,172 292.4 98.1 192.4 Philipsburg 14,380 120.8 46.1 74.4 Phoenixville 59,102 173.7 67.8 105.4 Pittsburgh 1,120,130 227.9 74.0 152.6 Pottstown 81,454 133.3 49.7 82.5 Pottsville 117,182 160.3 65.1 94.9 Punxsutawney 21,759 161.5 58.0 103.1 Quakertown 35,284 146.3 64.5 81.4 Reading 300,097 172.1 66.0 105.2 Renovo 3,848 (175.1) (67.4) (107.0) Ridgway 10,769 165.1 54.8 110.1 Ridley Park 94,485 192.9 65.9 124.5 Roaring Spring 23,081 95.1 39.9 55.1 Sayre 63,983 141.0 40.7 99.5 Scranton 222,667 192.9 70.3 122.0 Sellersville 89,066 173.0 67.6 104.5 Sewickley 79,854 226.0 75.8 148.3 Shamokin 21,106 204.4 69.3 134.0 Sharon 53,793 212.0 77.6 133.7 Somerset 39,440 170.9 60.8 107.7 Spangler 24,428 130.1 53.9 72.7 St Marys 25,270 151.7 52.6 98.9 State College 110,236 170.2 56.2 113.1 Sunbury 48,047 202.6 71.3 130.4 Susquehanna 12,155 158.5 55.8 102.3 Titusville 24,122 170.6 67.2 103.2 Towanda 20,627 154.1 58.1 95.5 Tunkhannock 22,387 122.9 56.4 66.3 Tyrone 17,259 132.8 47.2 85.5 Union City 8,890 121.9 53.7 68.2 Uniontown 82,693 172.4 61.0 110.9 Upland 116,969 192.0 55.7 135.2 Warminster 37,480 139.1 48.4 90.4 Warren 38,240 191.3 63.8 125.0 Washington 87,504 152.5 58.3 93.6 Waynesboro 45,794 142.4 62.7 77.5 Waynesburg 32,933 194.9 72.6 121.8 Wellsboro 39,437 163.1 72.9 89.8 West Chester 141,812 230.1 81.5 148.1 West Grove 41,564 172.2 59.8 112.1 Wilkes-Barre 221,488 186.8 73.2 113.1 Williamsport 88,829 158.3 47.6 109.9 Windber 16,485 144.5 56.1 87.6 York 278,302 157.9 63.4 94.5

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 1992-93.

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 (1992-93) The number of discharges per thousand Medicare enrollees varied by a factor of more than 1.7. Each point represents one hospital service area.

THE UTILIZATION OF HOSPITALS FOR MEDICAL AND SURGICAL CONDITIONS 117

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 (1992-93) 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.

THE UTILIZATION OF HOSPITALS FOR MEDICAL AND SURGICAL CONDITIONS 119

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 (1992-93) 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.

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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 (1992-93) 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.

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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.

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.

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 (1992-93) 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 1992-93 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 1992-93 had been attained for the residents of Philadelphia, 12,060 fewer discharges would have occurred in Philadelphia.

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. (1992-93) 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 1992-93 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.

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 (1992-93) 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 1992-93 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 1992-93 had been attained for the residents of Newark, 6,012 fewer discharges would have occurred in Newark.

THE UTILIZATION OF HOSPITALS FOR MEDICAL AND SURGICAL CONDITIONS 129 Benchmarking: High Variation Medical Conditions Figure 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. (1992-93) 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 1992-93 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.

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 5.11. Rates of Coronary Artery Bypass Grafting Procedures per 1,000 Medicare Enrollees in Hospital Service Areas in the Middle Atlantic States (1992-93) 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.

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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 5.12. Rates of Percutaneous Transluminal Coronary Angioplasty Procedures per 1,000 Medicare Enrollees in Hospital Service Areas in the Middle Atlantic States (1992-93) Rates of angioplasty varied by a factor of more than 10.6. Each point represents one hospital service area.

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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 5.13. 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 (1992-93) The number of Medicare enrollees undergoing invasive cardiovascular procedures was closely linked with the rate of diagnostic testing (R 2 =.70)

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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 5.14. Rates of Back Surgery Procedures per 1,000 Medicare Enrollees in Hospital Service Areas in the Middle Atlantic States (1992-93) Rates of back surgery varied by a factor of more than 8. Each point represents one hospital service area.

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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 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 (1992-93) 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.