Office of the Professions

News & Reports

Developing a Primary Care Agenda

Testimony for New York State Assembly Committee on Health, Richard N. Gottfried, Chair
Legislative Office Building, Roosevelt Hearing Room C, 2nd Floor, Albany, NY

by Frank Muñoz, Associate Commissioner, Office of the Professions

October 29, 2007

On behalf of the Board of Regents (BOR) and the State Education Department (SED), thank you for inviting us to share our views on the important challenge of providing competent and accessible primary care to the citizens of this State. The University of the State of New York (USNY), under the Board of Regents, has responsibility for education from pre-kindergarten through graduate schools, which includes the pre-professional and professional education and the examination standards for all health professions licensed under Title VIII of the Education Law and for licensing qualified professionals to provide the complete range of health care services to New Yorkers.

That jurisdiction extends to the licensing and registration of 47 professions, and practice oversight for 44. Included in the 47 professions, which number 750,000 professional licenses, are 40 health professions.

Today, I would like to focus on addressing the following points:

• What is Primary Care?
• How do we ensure that those who provide care are qualified and competent?
• As we work to ensure access, how do we maintain quality standards and prevent the illegal practice of the professions?

As we seek to assist this committee, we first ask that you consider primary care to extend beyond the physical care provided by physicians, physician assistants, specialist assistants, nurse practitioners and midwives. When focusing on primary care, it is important to remember the role of other licensed professionals in connecting patients to the health care system. For instance:

• Social workers, psychologists, and mental health professionals may be the first health care contact for American families dealing with stress, the growing prevalence of Alzheimer's and dementia, and veterans returning from Iraq and Afghanistan with Post-Traumatic Stress Disorder.
• There are compelling arguments for considering the dental professions as primary care providers because of the strong links between infections and diseases with manifestations in the oral cavity.
• As an example, consider the long-term consequences for a child who is misdiagnosed with a speech impairment and incorrectly placed in a Special Education program. A Speech-Language Pathologist may be the first to identify the true needs of that child.

Similar arguments can be made for many, if not all, of the other professions. This pertains particularly to those with direct access to patients at home, in workplaces, community based centers, schools and other settings that may not be considered "primary care" medical sites.

We urge you to accept our broader definition as a model that can have a substantial impact on the provision of primary care services to New York State residents. We're confident of that because each day we evaluate the curricula of a variety of health professions that demonstrate the high level of scientific education and training achieved by nurse practitioners, dentists, and others. It is incumbent upon us to conceive of a model of primary care that takes advantage of the intellectual talents and professional skills of these highly educated and dedicated individuals.

With that expanded definition across all of the professions, we thank you for asking the right questions, knowing that we must balance access and quality, and suggest that the ultimate model should include consumer choice and linkages between all providers involved. In developing models, we must ensure the quality of care and the protection of the public, using principles such as:

• Making clinical decisions based on the best interests of the patient rather than the financial interest of a business corporation.
• Educating professionals to exercise critical thinking in the discernment of the patient condition, rather than simply perform repetitive functions.
• Ensuring that primary care offered in particular settings by retail clinics or broad immunization programs contain necessary safeguards.

These principles have been the benchmark for previous collaborations between SED, the Department of Health, and the Legislature to solve challenges without undermining the quality of care and the competence of the individuals providing the care.

The Education Department serves as the pipeline to the workforce, playing a vital role in ensuring the quality of the professional workforce, responding to the demand for services in all settings - whether shortages are present or imminent - and exploring what can be done to address these demands while still ensuring the protection of the public.

On the adequacy of the workforce, we have shared with you a chart that reflects the number of licensees in 2007 and the trends from 18 years ago, including the addition of 95,000 new licensees in new professions created within those 18 years.

• The chart shows that the health professions traditionally deemed to provide primary care, including medicine and nursing, increased within a range of 7 to 26% over the 18-year period.
• In contrast, those health professionals who tend to have more numerous interactions with patients, such as physical and occupational therapists, grew in excess of well over 100%, some over 200%.
• Parenthetically, we note also that the Department's regulation of an additional 200,000 licensees is carried out with fewer staff than 10 years ago.

Despite these numbers, there is growing concern about shortages in a variety of health professions and the ability of the public to access care. There are additional data on shortages in health care areas and the effect on the delivery of care. For example, in nursing:

• There is growing concern about the impact of RN shortages on the quality of health care. A growing body of evidence demonstrates that hospitals with lower ratios of RNs to patients had more adverse events than hospitals with higher RN to patient ratios.
• Health care providers across a variety of settings reported increasing difficulty recruiting and retaining RNs, particularly in hospital settings.
• Our own information shows:
  • During each of the last seven years the Department has licensed an average of 10,000 new RNs, for a total of 70,000 new licensees since 2000.
  • However, the total registration count has seen only a net gain of 15,000. Thus 55,000 RNs have left the system due to retirement, out-of-state movement, or other factors.
  • NYS registered nursing programs have substantially increased their student load and these students are graduating. In 2000, NYS registered nursing programs graduated slightly more than 5,400 students compared to over 8,700 students in 2007.
  • Nonetheless, approximately 2,000 eligible applicants were denied access to New York nursing programs in 2007 as programs stated that they had reached capacity. Recruiting RNs with masters and doctoral degrees to teach in nursing programs is challenging because of low faculty salaries compared to what those professionals can receive in other health related areas.
• In Social Work, as another example,
  • The total supply of social workers has increased, but it is difficult to develop growth estimates due to lack of specific information on career paths after education.
  • Aggregate demand for social workers is increasing due to practitioners retiring and increased number of aging adults requiring more social work services.
• There are citizenship waivers for a number of professions that allow licensed individuals with legal immigration status to work in designated shortage areas. Unfortunately, the waivers for pharmacists expired last year and that has had a dramatic impact on service in some areas -just last week I spoke to a legislative office and conveyed that nothing could be done to extend the service of a Canadian pharmacist in Buffalo.
• In Physical Therapy, the U.S. Department of Labor findings show that there will be a significant demand for PTs that will not be met with the current and projected workforce. One challenge has to do with the Federal government's decision, at least for now, to discontinue providing special visa status to nurses and physical therapists, as they have in the past, for the shortage need. If this continues, there will be fewer foreign trained physical therapists and nurses as the delay in licensing those qualified foreign applicants will extend from the current 6-28 months to a projected 5-10 years.
• If the pipeline for International Medical Graduates (IMGs) is similarly affected, just conjecture at this point, the impact would be substantial:
  • IMGs comprise 35% of the total population of physicians.
  • IMGs comprise 27% of primary care physicians (total population of primary care is 18,225)
  • A subsequent report from the Albany Center for Health Workforce Studies, dated October 2007, reports that there are over 20,000 physicians providing primary care. There is no breakdown in that report as to how many are International Medical Graduates.
  • Relying on the October report and assuming the same percentage of IMGs, there are 5,400 IMGs providing primary care in NYS.

The Regents and the State Education Department have developed a number of initiatives to anticipate and address the shortage issues:

• We are working to ensure that new graduates get licensed as soon as practicable, and are removing unreasonable barriers. For example, last week the Regents approved a rule change that allows Veterinary Technologists to take the licensing examination six months before they complete their course of studies, so that upon completion they can almost immediately begin to practice. Many neighboring states have already adopted this practice, and our graduates will now be more competitive and more likely to seek employment in New York State.
• We have implemented online re-registration for all licensees, which, along with credit card payments, will significantly speed up re-registration.
• We are well on our way to automating initial licensure, including electronic transmissions of professional program transcripts and scanning of all documents. These steps will also speed up licensure, and will help address the 800,000 emails and telephone calls that we receive annually about licensure and practice issues.
• The Regents last week approved the Physician Shortage areas that were developed by SED and the Department of Health, which will help ease the financial burden for medical graduates who agree to work in these areas, including primary care and mental health shortage areas and allow for the temporary licensure of physicians in high needs areas without regard to citizenship.
• The Legislature provided the Department with legal authority to enforce the requirements for licensure to practice a profession. Last week, the Board of Regents approved regulations that are the first step to implementing the civil enforcement proceedings in cases of illegal practice of a profession.
• Planting the Seed: This is an exciting new initiative that takes full advantage of the comprehensive umbrella of the University of the State of New York by linking students with professionals in the field and with information about the education and qualifications necessary to pursue careers in the 47 licensed professions. This will improve both the educational experience of students as well as hopefully address these shortages as students benefit from mentoring, shadowing, and adopt a school strategies, modeled after many successful programs now conducted by the licensed professions.

I thank you for the opportunity to share our thoughts, and look forward to continuing to work with the Legislature as it addresses this challenge.