Immigration Status of International Medical Graduates and Physician Shortage in the US

1. Mary E. Ryan Mary E. Ryan

2. IMG: International Medical Graduates ECFMG: Educational Commission on Foreign Medical Graduates J1 Immigration status of IMGs sponsored by the ECFMG H-1B Immigration status of IMGs not sponsored by the ECFMG J-2 Spouse of J-1 Conrad 30: State Administered J-1 Waiver program DOS U.S. Department of State USCIS U.S. Citizenship and Immigration Services

3. Year Physician Supply (all specialties) Physician Demand (all specialties) Physician Shortage (all specialties*) Physician Shortage (non-primary care specialties) Year Physician Supply (all specialties) Physician Demand (all specialties) Physician Shortage (all specialties*) Physician Shortage (non-primary care specialties) 2008 699,100 706,500 7,400 None 2010 709,700 723,400 13,700 4,700 2015 735,600 798,500 62,900 33,100 2020 759,800 851,300 91,500 46,100 2025 785,400 916,000 130,600 64,800 Source: AAMC Center for Workforce Studies, June 2010 cited in AMA/IMGs in American medicine Contemporary Challenges and Opportunities, 1/2013 (IMG 2013) * Total: Primary Care, Surgical and Medical

4. Specialties Internal Medicine 3603 45.8% Pediatrics 861 11.0% Family Medicine 622 7.9% General Surgery 566 7.2% Psychiatry 412 5.2% Neurology 324 4.1% Obstetrics 151 1.9% Orthopaedic Surgery 113 1.4% Diagnostic Radiology 108 1.4% Anesthesiology 104 1.2% IMG 2013: citing ECFMG (2102) 2011 Annual Repor t www.ecfmg.org

5. Number of Physicians in the U.S. 985,375 Number of IMG Physicians in the U.S. 254,396 % IMG physicians in U.S. 25.8 % IMGs in residency programs 26.3* % IMGs in patient care 75.5 55.1% office/20.4% Hospital % IMGs on full-time staff 29.9 % IMGs in research 19.9 % IMGs in medical teaching 16.7* % IMGs in administration 12.0 * Percentages exclude residents/fellows. IMG 2013 Citing Source: AAMC Center for Workforce Studies, June 2010

6. 2011 2010 2009 2008 2007 2006 Positions offered 2,708 2,608 2,535 2,603 2,711 2,761 Positions filled 2,555 1,169 2,311 1,370 2,299 2,307 % filled 94.0% 91.4% 91.2% 90.6% 88.3% 85.0% Filled by U.S. seniors 1,301 1,169 1,071 1,156 1,096 1,123 % filled by U.S. seniors 48.0% 44.8% 42.2% 43.9% 42.1% 41.4% IMG 2013 citing National Resident Matching Program

7. IMGs: Are motivated applicants Must be sponsored by an employer to remain in the U.S. Need early decision Ideally, close to a year in advance

8. Timing Strictures of immigration system Cost of mistakes Must plan for the future now

9. Create certainty by: Having policies and procedures set up before you recruit IMGs that meet the requirements of waivers and beyond Swift execution of requirements

10. No two year home residence requirement Must file H-1B to transfer physician Finite number of H-1Bs available each year for cap-subject employers Cap-exempt non-profit organizations affiliated with an institution of higher education Six year limit May need to initiate permanent residence immediately

11. Two year home residence requirement Waiver of HRR Hardship or Persecution Interested Government Agency (IGA) based on service in a medically underserved area Conrad State 30 program Federal agencies: Delta Regional Authority Appalachian Regional Commission Department of Health and Human Services

12. Subject to spouses two year home residence requirement Spouse must obtain waiver before J-2 can file to change status Cannot change status in U.S. to H-1B

13. Purpose: Bring physicians into medically underserved communities Keep physicians in the community to permanently address shortages

14. Programs favor primary care Specialists permitted May require additional documentation May be accepted only after primary care applications are accepted

15. Generally for all IGA programs Worksite(s) in Federally designated medically underserved areas HPSA/MUA http://www.hrsa.gov/shortage/find.html Conrad 30 State Program State may permit up to 10 Flex spots Prepare to show service to patients in underserved areas May be considered only after waivers for HPSA/MUA

16. 3 year contract Full-time/ minimum 32 hours direct patient care Address of worksites No non-compete Statement re: compliance with J-1 policies by both parties to the contract Compliance with prevailing wage obligation Start within 90 days of receipt of waiver

17. Applications require: 6 months of evidence of unsuccessful recruitment Evidence of facilitys patient mix: Commercially insured Medicaid/Medicare Sliding Fee Public notice that all patients will be seen regardless of ability to pay

18. Procedures: Physician obtains Waiver case number from DOS Employer/physician submit waiver application to the State 30 administrator October 1 st State recommends waiver and sends to DOS DOS recommends waiver and sends to USCIS USCIS approves waiver

19. After approval* by USCIS, H-1B petition filed by employer with USCIS (* possible to file with DOS recommendation) Upon approval of H petition and change of status, physician commences employment Reports arrival to practice to the State Yearly confirmations of continued employment Changes in practice site/contract must be reported to State and to USCIS

20. H-1Bs completing J-1 service requirement may transfer obligation to new employer if extenuating circumstances Extenuating define on case-by-case basis Not counted again Direct filing with USCIS Obtaining State approval bolsters transfer request. Must complete full 3 years of service

21. Change of start date Change of salary Change of practice site Performance

22. Permanent Residence a/k/a Green Card Request may arise in recruitment Long wait for visas India/China Ability for spouse to obtain work authorization Currently H-4s not permitted to work

23. Immigrant visas are authorized per country/per category A visa must be available in order to file for adjustment of status or immigrant visa There are backlogs in certain categories and certain countries, notably including India and mainland China

24. http://travel.state.gov/conte nt/visas/english /law-and-policy/bulletin.html Employm ent- based All China Mainland India Mexico Philippin es 1 st C C C C C 2 nd C Nov 15, 2009 May 01, 2009 C C 3ed Oct 1, 2011 April 1, 2009 Nov 15, 2003 Oct 1, 2011 Oct 1, 2011

25. Establish basis Employment/Family Application to register permanent residence Physicians must complete 3 year J-1 service obligation* Spouse and children are derivative beneficiaries Interim travel and work benefits

26. Employer must file labor certification with Department of Labor Must provide evidence of unavailability of U.S. workers Specific recruitment procedures must be followed Employer files immigrant petition with USCIS based on approval of labor certification Physician files application to register permanent residence 3 year service obligation completed Visa available

27. Immigrant Petition with USCIS Must be based on 5 year contract for work in underserved area Dated less than 6 months before filing Typically amend J-1 service contract; add 2 years Must obtain support letter from State May file application to register permanent residence even 3 year obligation not completed if visa available Must complete 5 years to obtain green card

28. Immigration law is a mystery and a mastery of obfuscation... -USCIS spokeswoman Karen Kraushaar

29. Mary E. Ryan Taylor & Ryan, LLC 1777 Reisterstown Road, Ste. 265 Baltimore, MD 21208 mryan@taylor-ryan.com 410.412.3467