New york pcmh chartbook 2013

A C H A R T B O O K

Patient-Centered Medical Homes in New York: Updated Status and Trendsas of July 2013

United Hospital Fund

The United Hospital Fund is a health services researchand philanthropic organization whose primary mission is toshape positive change in health care for the people of NewYork. We advance policies and support programs that promotehigh-quality, patient-centered health care services that areaccessible to all. We undertake research and policy analysisto improve the financing and delivery of care in hospitals,health centers, nursing homes, and other care settings. Weraise funds and give grants to examine emerging issues andstimulate innovative programs. And we work collaborativelywith civic, professional, and volunteer leaders to identifyand realize opportunities for change.

OFFICERS

J. Barclay Collins IIChairman

James R. Tallon, Jr.President

Patricia S. LevinsonFrederick W. Telling, PhDVice Chairmen

Sheila M. AbramsTreasurer

Sheila M. AbramsDavid A. GouldSally J. RogersSenior Vice Presidents

Michael BirnbaumDeborah E. HalperVice Presidents

Stephanie L. DavisCorporate Secretary

DIRECTORS

Richard A. BermanJo Ivey Boufford, MDRev. John E. CarringtonDerrick D. CephasPhilip ChapmanDale C. Christensen, Jr.J. Barclay Collins IIRichard CottonMichael R. Golding, MDJosh N. KuriloffPatricia S. LevinsonDavid Levy, MDHoward P. MilsteinSusana R. Morales, MDRobert C. OsbornePeter J. PowersMary H. SchachneJohn C. SimonsMichael A. Stocker, MD, MPHJames R. Tallon, Jr.Frederick W. Telling, PhDMary Beth C. Tully

HONORARY DIRECTORS

Howard SmithChairman Emeritus

Douglas T. YatesHonorary Chairman

Herbert C. BernardJohn K. CastleTimothy C. ForbesBarbara P. GimbelRosalie B. GreenbergAllan Weissglass

U N I T E D H O S P I T A L F U N D

Patient-Centered MedicalHomes in New York:Updated Status and Trends as of July 2013

Gregory BurkeD I R E C T O R , I N N O VA T I O N S T R A T E G I E S

U N I T E D H O S P I T A L F U N D

Copyright 2013 by United Hospital Fund

ISBN 1-933881-38-0

Free electronic copies of this report are available atthe United Hospital Fund’s website, www.uhfnyc.org.

Patient-Centered Medical Home Update, 2013 1

This chartbook tracks the growth of patient-centered medical homes (PCMHs) in New YorkState. It builds on analyses of NationalCommittee for Quality Assurance (NCQA) datapresented in two prior United Hospital Fundreports: The Patient-Centered Medical Home:Taking a Model to Scale in New York State (2011)and The Evolution of Patient-Centered MedicalHomes in New York State: Current Status andTrends as of September 2012 (2012).

Like those earlier reports, this update describestrends in the number of providers in New YorkState working in NCQA-recognized PCMHs,provides insights into the adoption and spread ofthe PCMH model over the past three years, andidentifies some issues for consideration by theprovider community, payers, and the New YorkState Department of Health (NYSDOH) as themedical home movement matures.

The following sections and the charts to whichthe narrative refers describe changes in thenumber of providers working at NCQA-recognized PCMHs in New York from threeperspectives:

• Status of PCMH adoption in New York as ofJuly 2013 (Figures 1-13)

• Growth in PCMH adoption between July2011 and July 2013 (Figures 14-22)

• Year-by-year trends for each region, bypractice type (Figures 23-34)

HighlightsNew York State leads the nation in the adoptionof the medical home model, as measured by thenumber of practices recognized by the NCQA aspatient-centered medical homes and the numberof PCMH providers—that is, providers workingin those practices.

Roughly half of all PCMH providers in the state

are in New York City and half are in non-NYCregions. Those regions (and, within New YorkCity, the boroughs) vary markedly from eachother in terms of the penetration of the PCMHmodel and the type of practice in which thePCMH providers work.

After a period of rapid growth, the adoption ofthe PCMH model in New York State has slowed.Between 2011 and 2013, the number of PCMHproviders in New York grew by 44 percent, fromroughly 3,500 to nearly 5,000. Most of thatgrowth occurred between 2011 and 2012, muchof it in upstate regions. Between 2012 and 2013,the number of PCMH providers in the stategrew by only 5 percent.

As of July 2013, 80 percent of the NCQA-recognized PCMH providers in New York Statewere recognized under NCQA’s 2008 standards.To maintain NCQA recognition, those practiceswill need to meet the NCQA’s more rigorous2011 standards over the next few years. A substantial portion of the cohort recognizedunder NCQA’s 2008 standards, receivedrecognition as a Level 1 or Level 2 PCMH.These practices (which include a large numberof small practices) may have more difficultyretaining NCQA recognition.

AcknowledgmentsThis analysis would not have been possiblewithout the support of Kate Bliss from theOffice of Quality and Patient Safety in the NewYork State Department of Health. Kate was ofenormous assistance in acquiring, scrubbing,and formatting the NCQA data files for this setof reports.

This report was supported in part by the AltmanFoundation, TD Charitable Foundation,EmblemHealth, New York Community Trust,and Excellus BlueCross BlueShield.

Introduction

2 United Hospital Fund

MethodsTo produce this analysis, UHF received threedata files from the New York State Departmentof Health (originally generated by the NCQA)listing all providers working in NCQA-recognized PCMHs as of three specific dates:July 1, 2011; July 1, 2012; and July 1, 2013.These files included all providers in New YorkState working in practices recognized by theNCQA as patient-centered medical homes,along with basic demographics and descriptors,enabling us to assign them to geographic regionsand practice type.

For consistency, we have maintained thedefinitions of the metrics used in prior reports.

PCMH Providers: This includes all providerslisted as active in the NCQA reports: physicians(MD and DO) and mid-level providers (e.g.,nurse practitioner and physician’s assistant).1

NCQA Standards and Level of NCQARecognition: Practices have received three-yearNCQA recognition under either the 2008 or the2011 standards, along with level of recognition(Level 1, 2, or 3 PCMH).The original NCQAPPC-PCMH Standards, published in 2008(referred to in this report as the 2008 standards),were used by the NCQA in its originalrecognition process for all PCMHs. In 2011, theNCQA published and began to use a revised setof standards for PCMH recognition.

The 2011 standards include changes in thenumber of “must-pass” elements, and in theweighting and scoring of a number of measuresthat determine the different levels ofrecognition.

Providers applying for PCMH recognition afterJanuary 1, 2011, were reviewed using the 2011standards, as are those providers who were

recognized under the 2008 standards applyingfor recertification.

New York State Regions: In these reports, wehave used a variant of New York State’sinsurance regions as a way of grouping andanalyzing PCMH Providers into seven regions: • New York City (also analyzed at a borough

level, given its size and diversity)• Long Island• Hudson Valley • Albany/Northeast New York• Rochester Area• Syracuse/Central New York• Buffalo/Western New York

Practice Type: Providers who work withindifferent practice contexts (large group vs. solopractice, for example) often have access todifferent infrastructure and resources—e.g.,electronic medical records and care managers—and they face different challenges in achievingand sustaining PCMH recognition. In order todistinguish among these different settings(which in some cases are also markers forpopulations served) we use six different practicetypes first established in the 2011 PCMHreport:• Group Practice: Large and small groups,

with five or more physicians listed on theNCQA roster

• Health Center: Federally qualified healthcenters and state-licensed diagnostic andtreatment centers

• HHC: New York City’s Health and HospitalsCorporation

• Hospital Clinic: On-site or community-based clinics of hospitals

• Hospital/AMC Practice: Private practicesand faculty practice plans based in hospitalsand academic medical centers (AMCs)

• Practice: Small private practices, with fewerthan five physicians listed on the NCQAroster

1 This report updates the PCMH data published in The Evolution of Patient-Centered Medical Homes in New York State: Current Status andTrends as of September 2012. That report was based on data received from the New York State Department of Health (NYSDOH),which inadvertently included a number of providers and practices whose NCQA recognition had expired, resulting in an overcount ofproviders working in NCQA-recognized PCMHs. In preparing this report we worked with NYSDOH staff to verify the “active” statusof all practices and providers as of July of all three years (2011, 2012, and 2013) and verified these figures with NCQA staff.

Total PCMH Providers New York State has led the nation in theadoption of the medical home model. Based on arecent review of NCQA data (which counts bothNCQA-recognized practices and providersworking in those practices), New York is home toone-sixth of the total number of NCQA-recognized PCMHs in the nation (Figures 1 and2).

Examining only the number of PCMH providers(physicians and mid-level practitioners) who areworking in practices that have achieved NCQArecognition as PCMHs is a more accuratemeasure of clinical capacity. As of July 2013,NCQA data showed that there were 4,908providers working in practices that had receivedNCQA recognition as PCMHs in New York.

As shown in Figure 3, roughly half of the total(2,533 PCMH providers, or 52 percent) were inNew York City, and half (2,375, or 48 percent)were in other regions of the state.

Distribution by Region The number of PCMH Providers in New YorkState varied widely both by region of the stateand within New York City, as shown in Figures 4and 5.

Distribution by Practice Type The PCMH model is not evenly distributedacross different types of practices. Figure 6depicts the distribution of providers working inPCMH practices by practice type for the state asa whole.

Statewide, large group practices and healthcenters—organizations with the scale and

infrastructure to more readily support thePCMH model—accounted for the largestnumbers of PCMH providers, followed by theNew York City Health and HospitalsCorporation, hospital clinics, and hospital/AMCpractices. Small practices (practices with fewerthan five providers), which have the least scaleand infrastructure, made up the smallest cohort.

There were marked differences between NewYork City and the rest of the state in thecomposition of PCMH providers by practicetype (Figures 7 and 8).• Outside New York City, half of the PCMH

providers worked in large group practices. • In New York City, group practices were a far

smaller proportion of the total (11 percent),while hospital clinics (including HHC) andhospital/AMC-based practices and facultypractice plans were the dominant practicetype (78 percent, in aggregate).

The NYSDOH Hospital Medical Home programwill likely increase the number of providers inhospital teaching clinics achieving NCQArecognition under the 2011 standards over thenext year. There is presently no equivalentprogram or initiative focused on providersworking in other practice types.

Distribution by practice site also variedsignificantly among regions in the state (Figures9 and 10).

Outside New York City, all regions showed asubstantial proportion of PCMH providers inlarger groups in 2013; Hudson Valley and Albanyhad the largest cohort within health centers; andSyracuse and Rochester had the largestconcentrations within hospital clinics andhospital/AMC-affiliated practices, respectively.


Status of PCMH Adoption in New York State as of July 2013


Similar differences existed within New York City.The HHC and health centers were consistentlystrong across the four larger boroughs, but therewere differences among the boroughs in theimportance of groups, hospital clinics and smallpractices. Manhattan had by far the largestconcentration of PCMH providers withinhospital/AMC practices, largely a function of theadoption of the PCMH model by Manhattan-based medical school faculty practices.

Year and Level of NCQA Recognition As is shown in Figure 11, 3,905 (80 percent) ofthe state’s 4,908 NCQA-recognized PCMHproviders worked in practices recognized at Level1, 2, or 3 under NCQA’s 2008 standards. To

maintain recognition, these practices will needto reapply for NCQA recognition under NCQA’smore rigorous 2011 standards.

Of the PCMH providers recognized underNCQA’s 2008 standards, 588 (15 percent of the2008 total) work in practices that wererecognized at Level 1 or 2, and they may havegreater difficulty meeting—or may be unwillingto meet—NCQA’s 2011 standards, resulting insome practices losing NCQA recognition.

As is shown in Figure 12, small practices facethe most substantial challenge: many wererecognized under the 2008 standards at Level 1or Level 2. These practices represent over one-third (37 percent) of all small practices withNCQA recognition as PCMHs (Figure 13).


Overall GrowthThe number of providers working in NCQA-recognized PCMHs grew by 44 percent over thethree-year period, increasing from a statewidetotal of 3,399 in July 2011 to 4,908 in July 2013(Figure 14). As shown in Figure 15, however,that growth was not uniform; it was different inNew York City than in other parts of the state.

While New York City had 2,054 PCMHproviders in 2011, its growth between 2011 and2012 was only 15 percent, and between 2012and 2013 the rate of growth fell to 7 percent.New York City accounted for 60 percent of thestate’s total PCMH providers in 2011 butroughly 50 percent in 2012 and 2013.

Regions outside New York City had a differenttrajectory. Non-NYC regions, which had 1,345PCMH providers in 2011, grew to 2,298 in2012, an increase of 71 percent. However,between 2012 and 2013 this rate of growthdeclined sharply, to only 3 percent.

Non-NYC regions’ share of the state’s totalPCMH providers grew from 40 percent in 2011to roughly 50 percent in 2012, and remained atthat level in 2013.

Regional Differences in GrowthOutside New York City, the number of PCMH

providers grew substantially between 2011 and2013 in all upstate regions, particularly inSyracuse (Figure 16).

In New York City (Figure 17), there was lessimpressive growth, roughly equivalent across theboroughs, with the exception of Staten Island.Growth in the number of PCMH providersbetween 2011 and 2013 was evenly spreadacross all practice types (Figure 18), with theexception of the Health and HospitalsCorporation, which had already achieved NCQArecognition for essentially all of its primary careclinics by 2011.

Looking at the growth in PCMH providers on ayear-by-year basis shows a somewhat differentpicture. As is shown in Figure 19, there areindications that, after rapid expansion in theadoption of the PCMH model between 2011and 2012 (when the number of PCMHproviders in the state grew by 37 percent), therate of growth in the PCMH model leveled off in2013 to a rate of only 5 percent.

That decline in the rate of growth was statewide:each of the non-NYC regions grew at roughly thestatewide average between 2012 and 2013(Figure 20) and—with the exceptions of Queensand Staten Island—in New York City (Figure21). That phenomenon was evenly spread acrosspractice types as well (Figure 22).

Growth in PCMH Adoption, July 2011 to July 2013


Notwithstanding the modest rate of growth overthe past year, essentially every region in NewYork showed a substantial increase in thenumber of PCMH providers between 2011 and2013.

As is shown in Figures 23-34, the regions variedconsiderably from one another in numbers ofPCMH providers, the types of practices adoptingthe PCMH model, and patterns of growth.

• In Albany/Northeast New York, where thePCMH census was evenly spread amongpractice types in 2011 (with groups thelargest cohort), there was marked growth ingroups and hospital clinics in 2012, whichheld in 2013 (Figure 23).

• In Buffalo/Western New York, where thePCMH census was dominated by groups in2011, there was further growth in groups, aswell as in health centers and practices in2012 and 2013 (Figure 24).

• In the Hudson Valley, which was dominatedby groups and health centers in 2011, therewas further growth in both types in 2012, andin groups in 2013 (Figure 25).

• Long Island—which had the lowest PCMHpenetration of any region, largely composedof groups—there was slight growth in 2012,which leveled off in 2013 (Figure 26).

• In Rochester, where the PCMH census wasrelatively evenly spread in 2011 amongGroups, Health Centers, Hospital Clinics,and Hospital/AMC Practices, there wassubstantial growth in 2012, driven in largepart by an increase in Hospital/AMCpractices (Figure 27).

• In 2011, Syracuse/Central New York had acomparatively low PCMH penetration; itincreased considerably in 2012, driven by amajor increase in hospital clinics and groups(Figure 28).

Within New York City, the boroughs were

similarly diverse in the composition and growthtrajectories by practice type between 2012 and2013.

• In 2011, New York City as a whole (Figure29) had a PCMH profile that was quitebroadly based, with HHC, hospital clinics,health centers, and hospital/AMC practicesall accounting for substantial proportions ofthe total. In 2012 each showed overallgrowth, with the largest absolute growth inhealth centers, HHC, and practices.

• The Bronx, whose PCMH profile was moreinstitutionally based in 2011 (includinghealth centers, HHC, hospital clinics, andhospital/AMC Practices), grew in both healthcenters and HHC (Figure 30).

• Brooklyn, which in 2011 had the largestproportion of its PCMHs in HHC (and fewerin groups, health centers, hospital clinics,and practices), showed growth in healthcenters and hospital clinics (Figure 31).

• Manhattan (Figure 32), which in 2011 had arelatively even spread of PCMHs acrosshealth centers, HHC, and hospital clinics(and the state’s largest cohort ofhospital/AMC practices), grew slightly in allpractice types. (Note: the number of PCMHproviders shown for hospital clinics in 2011was overstated as a result of some duplicatereporting; when corrected for that overcount,the net growth in hospital clinics between2011 and 2013 was in line with that of theother boroughs.)

• Queens (Figure 33), which has a strongerpresence of groups and small practices thanthe other boroughs, experienced most of itsgrowth between 2011 and 2013 in smallpractices.

• Staten Island (Figure 34), which had thesmallest number of PCMHs of any borough,was spread between groups and practices in2011, both of which grew slightly in 2012and 2013.

Year-by-Year Trends for Each Region


While New York State continues to lead thenation in the adoption of the PCMH model ofcare, and the medical home model is continuingto grow in New York, that growth appears to beleveling off. In addition, while the statewidegrowth trajectory has been impressive, it maskssubstantial variation in the adoption of thePCMH model by practice type and region.

To date, the model’s greatest penetration hasbeen among larger practices that have the scaleand infrastructure required to operate as amedical home. Considerable investment andeffort—and better alignment between payers andproviders—will be necessary to increase theadoption of the medical home model amongsmaller practices, which often lack the resources

to mount and sustain the PCMH model.

Similarly, the substantial variation across thestate in the distribution and spread of thePCMH model reflects a series of region-specificfactors, including (and perhaps especially) theunderlying composition of the regions’ primarycare systems. This argues for the use of region-specific approaches to stimulating andsupporting further growth in medical homesacross the state.

Further discussion of these issues is included inan accompanying issue brief, Advancing Patient-Centered Medical Homes in New York, availableon the United Hospital Fund’s website,www.uhfnyc.org.

Conclusion


Figures 1-13:PCMH Status as of July 2013

P 1


Figure 1. NCQA-Recognized PCMHs,New York vs. Other States, 2013

Note: Includes both practices recognized as PCMH and providers working in those practices. Data as of October 2013; all other figures in this report show data current as of July 2013.

Source: National Committee for Quality Assurance. Available at http://recognition.ncqa.org/index.aspx (accessed October 7, 2013).

1

NYS PCMH, 6,27617%

Other States, 30,80683%


Figure 2. PCMHs (Practices and Providers) in New York, Other States, and the United States

P 1

State2008

Standards2011

Standards Total in StatePctg. of U.S.

TotalCalifornia 218 2,227 2,445 7%Florida 515 589 1,104 3%Illinois 686 447 1,133 3%Massachusetts 711 819 1,530 4%Michigan 556 167 723 2%New Jersey 421 307 728 2%

North Carolina 1,882 605 2,487 7%

Pennsylvania 1,761 828 2,589 7%New York 4,859 1,417 6,276 17%Texas 1,221 447 1,668 4%Washington 594 364 958 3%Other States 7,630 7,811 15,441 42%U.S. Total 21,054 16,028 37,082 100%

Note: NCQA data include practices recognized as PCMHs and providers working in those practices.

Source: NCQA Recognition Directory. Available at http://recognition.ncqa.org/index.aspx (accessed October 7, 2013).


Figure 3. New York State Providers in PCMHs, July 2013

1

Non-NYC, 2375, 48%

NYC, 2533,52%


Figure 4. Non-NYC Providers in PCMHs, by Region, July 2013

P 1

0

100

200

300

400

500

600

Albany/NE NY Buffalo Area Hudson Valley L.I. Rochester Area

Syracuse/Cent NY


Figure 5. NYC Providers in PCMHs, by Borough, July 2013

1

0

200

400

600

800

1,000

1,200

Bronx Kings New York Queens Richmond


Figure 6. New York State Providers in PCMHs, by Practice Type, July 2013

P 1

Group, 1459, 30%

Health Ctr, 973, 20%HHC, 546

11%

Hosp Clinic, 875, 18%

Hosp Px, 583, 12%

Practice, 472, 9%


Figure 7. Non-NYC Providers in PCMHs, by Practice Type, July 2013

18 U d Hospital Fund

Group1,18150%

Health Ctr42418%

Hosp Clinic38916%

Hosp Px1948%

Practice1878%


Figure 8. NYC Providers in PCMHs, by Practice Type, July 2013

P 1

Group27811%

Health Ctr54922%

HHC54622%

Hosp Clinic48619%

Hosp/AMC Px38915%

Practice28511%


Figure 9. Non-NYC Providers in PCMHs, by Region and Practice Type, July 2013

2

0

100

200

300

400

500

600

Albany/NE NY Buffalo Area Hudson Valley L.I. Rochester Area Syracuse/Cent NY

Group Health Ctr HHC Hosp Clinic Hosp Px Practice


Figure 10. NYC Providers in PCMHs, by Borough and Practice Type, July 2013

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0

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1,000

1,200

Bronx Kings New York Queens Richmond



Figure 11. New York State Providers in PCMHs, by NCQA Program and Level, July 2013

2

Level 1: 10 (0%)

Level 2: 57 (1%)

Level 3:936 (19%)

Level 1: 405 (8%)

Level 2: 183 (4%)

Level 3:3,317 (68%)


Figure 12. New York State Providers in Practices Recognized Under NCQA’s 2008 Standards as Level 1 and Level 2 PCMHs (N=588 Providers)

P 2

Group Health Ctr Hosp Clinic Hosp Px PracticeLevel-1 64 65 70 47 159Level-2 30 39 81 16 17

0

20

40

60

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120

140

160

180


Figure 13. Proportion of New York State Providers in Practices Recognized Under NCQA’s 2008

Standards as Level 1 and Level 2 PCMHs, July 2013

2

Group Health Ctr HHC Hosp

Clinic Hosp Px Practice

2008 Levels 1 and 2 6% 11% 0% 17% 11% 37%

0%

5%

10%

15%

20%

25%

30%

35%

40%


Figures 14-22: Growth in PCMH Adoption,

July 2011 to July 2013

2


Figure 14. Number of New York State Providers in NCQA-Recognized PCMHs, 2011 and 2013

P 2

2011 2013PCMH Providers in NYS 3,399 4,908% Growth 44%

0

1,000

2,000

3,000

4,000

5,000

6,000


Figure 15. Growth in PCMH Providers, NYC vs. Rest of State, 2011-2013

2

NYC Non-NYC2011 2,054 1,3452012 2,366 2,2982013 2,533 2,375

0

500

1,000

1,500

2,000

2,500

3,000


Figure 16. Changes in Non-NYC PCMH Providers by Region, 2011-2013

P 2

0

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Albany/NE NY Buffalo Area Hudson Valley L.I. Rochester Area Syracuse Central NY

2011 2013


Figure 17. Changes in NYC PCMH Providers by Borough, 2011-2013

3

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1,000

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Bronx Brooklyn Manhattan Queens Staten Island

2011 2013


Figure 18. Changes in New York State PCMH Providers by Practice Type, 2011-2013

P 3

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1,400

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2011 2013


Figure 19. Number of New York State Providers in NCQA-Recognized PCMHs, 2011-2013

3

2011 2012 2013PCMH Providers in NYS 3,399 4,664 4,908% Growth vs Prior Year 37% 5%

0

1,000

2,000

3,000

4,000

5,000

6,000


Figure 20. Changes in Non-NYC PCMH Providers by Region, 2012-2013

P 3

0

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400

500

Albany/NE NY Buffalo Area Hudson Valley L.I. Rochester Area Syracuse Central NY

2012 2013


Figure 21. Changes in NYC PCMH Providers by Borough, 2012-2013

3

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400

600

800

1000

1200

Bronx Brooklyn Manhattan Queens Staten Island

2012 2013


Figure 22. Changes in New York State PCMH Providers by Practice Type, 2012-2013

P 3

0

200

400

600

800

1,000

1,200

1,400

1,600


2012 2013


Figures 23-34: Year-by-Year Trends by Region,

2011-2013

P 3


Figure 23. Albany/Northeast New York

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Group Health Ctr Hosp Clinic Practice

2011 2012 2013


Figure 24. Buffalo Area

P 3

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Group Health Ctr Hosp Clinic Hosp Px Practice

2011 2012 2013


Figure 25. Hudson Valley

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Group Health Ctr Hosp Px Practice

2011 2012 2013


Figure 26. Long Island

4

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140

Group Health Ctr Hosp Px Practice

2011 2012 2013


Figure 27. Rochester Area

4

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2011 2012 2013


Figure 28. Syracuse/Central New York

P 4

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2011 2012 2013


Figure 29. New York City

4

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2011 2012 2013


Figure 30. Bronx

P 4

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2011 2012 2013


Figure 31. Brooklyn

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2011 2012 2013


Figure 32. Manhattan

P 4

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2011 2012 2013

Note: The number of PCMH providers shown for hospital clinics in 2011 was overstated as a result of some duplicate reporting; when corrected for that overcount, the net growth in hospital clinics between 2011 and 2013 was in line with that of the other boroughs.


Figure 33. Queens

0

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Group Health Ctr HHC Hosp Clinic Practice

2011 2012 2013


Figure 34. Staten Island

P 4

0

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8

12

16

Group Practice

2011 2012 2013

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