J-1 Visa Waivers: A Tool to Recruit International Physicians

1. J-1 Visa Waivers: A Tool to Recruit International Physicians Alaska Tribal Health Directors Nov. 17, 2009 PANEL Pat Sammartino, ANTHC Statewide Recruiting Manager TriptaaSurve, MPH, JD, Alaska DHSS Health Planning SupriyaMathur, MD, ANMC ENT Physician John Kokesh, MD, ANMC ENT Clinic Chief

2. Why International Physicians? • 2006 Alaska Physician Supply Task Force: Alaska needs a net gain of 59 new physicians per year to offset losses to retirement and outmigration. Tribal facilities have very high vacancies. • The Association of American Medical Colleges (AAMC): The U.S. has a significant shortage of physicians, and its growing. • Health facilities responding by hiring international physicians. According to a recent WWAMI study, international physicians now constitute about 25% of all practicing physicians in the U.S. • The WWAMI study concludes that “International Medical Graduates (IMGs) are a core component of the primary care system, and must be considered in planning the future medical workforce."

3. International Physicians Completing U.S. Residencies • Most international physicians initially come to the U.S. for graduate medical education (residency). The most common visa for a residency is the J-1 visa. • The J-1 visa requires that upon completion of the residency, the international physician must return to his/her home country for at least two years before returning to the U.S. However, many international physicians wish to stay. • One way to avoid the J-1 visa return-home requirement is to get a J-1 waiver. • To qualify for a waiver, an international physician completing a U.S. residency must enter into an employment agreement to work in a HPSA or MUA for at least three years. Under federal law, tribal facilities can qualify as HPSA-based. • Sponsorship by State of Alaska or a federal agency is required. The federal law authorizing States to sponsor 30 waivers per year is called “State-30 program.”

4. Many U.S. medical residents are IMGs.Of all 2008 U.S. medical residencies offered: • International Medical Graduates definition does not include U.S. citizen graduates of international medical schools or Canadians. • IMGs account for one-fourth of the nation’s practicing physicians. • Data source: 3Rnet (National Rural Recruitment and Retention Network)

5. The State-30 waiver program • The State-30 J-1 visa waiver program is also called the “Conrad 30” Program, after Senator Kent Conrad, who sponsored the authorizing legislation. It became law in 1994, allowing each state to sponsor 20 J-1 visa waiver applications to the State Dept. per year. • The law was amended in 2002 to reauthorize the program and increase the number of waivers available to each state to 30 per year. It has been amended and reauthorized several times since then. • The purpose of the law is to increase the availability of physician services in federally designated shortage areas.

6. Alaska State-30 waiver program • Under federal law, Alaska (via DHSS) can sponsor up to 30 J-1 visa waiver applications per year. • Some states (e.g. Washington) use all 30 waiver slots each year. Competition for the slots is intense. • Alaska’s waiver program is underutilized compared to other states. The great majority of slots go unused. • Alaska’s unused J-1 waiver slots may be a resource for tribal providers to attract international physicians who have completed U.S. residency programs.

7. HRSA also sponsors J-1 waivers: “National Interest Waivers” (NIW) • Primary Care Only • Health Professional Shortage Area (HPSA) score of 7 or higher • Eligible Facilities: • A Federally Qualified Health Center • A Rural Health Clinic • American Indian/Alaskan Native tribal facilities, as defined by P.L. 93-638 Source: http://www.globalhealth.gov/exchangevisitorprogram/index.html

8. Process to Obtain State-30 Waiver Physician While on J-1 visa, begins to seek employment opportunities during last year of residency, or completes residency. Needs to find MUA- or HPSA-based facility willing to employ him/her for 3 years. U.S. State Department – length of time 4-8 weeks Processes physician’s case number application, reviews state agency’s waiver request, and makes recommendation to Dept Homeland Security Waiver Process: U.S. Dept of Homeland Security – length of time 4-8 weeks Reviews recommendation, grants waiver of the 2-year home residence requirement, and notifies physician of approval. Also, reviews and approves employer’s petition for physician to obtain H-1B work visa Physician Submits Form DS-3035 - J-1 Visa Waiver Review Application to Department of State to obtain case number • Employer • Recruits, interviews and screens physician per normal processes • Enters into contingent 3-year employment agreement with physician • Applies to Alaska DHHS to request a J-1 visa waiver for physician Physician Upon approval of waiver and granting of H-1B work visa by Dept. Homeland Security, must commence employment within 90 days. Physician Upon fulfillment of 3-year employment contract, may apply for 1-time extension of H-1B work visa, seek other type of visa, seek permanent work status, or return to home country. • Alaska DHHS – length of time varies (Triptaa Surve, Health Planning) • Reviews waiver request, employment contract, and all paperwork • Submits complete waiver request package to U.S. State Department • May request waivers for up to 30 physicians per year 8

9. EmploymentAgreement Requirements (May be able to just amend existing template) Minimum 40 hours per week of clinical services In Medically Underserved Area / Health Profession Shortage Area (MUA/HPSA) – with exception 3-year minimum period of time At least Alaska prevailing wage Physician must agree to commence employment within 90 days of Homeland Security approval 9

10. Immigration Legal Services • Immigration law firms can assist tribal facilities prepare and file the paperwork required for a J-1 waiver. Upon approval of the J-1 waiver, they petition the government to issue a H-1B temporary work visa to the physician so he/she can fulfill 3-year contract with tribal facility. • TheHammond Law Group provide services at flat rates (not hourly) so facilities may budget for the costs of international physicians. The average cost for a J-1/H-1B temporary work authorization package is $6,000. Filing fees not included. Contact: Attorney Sherry Neal at sln@hammondlawfirm.com • Another J-1 waiver law firm is Stephen Jeffries and Associates, NY. Website: http://www.jeffries-law.com/Flat rates are also available. • Another J-1 waiver law firm is Aronson and Associates, MN. Website: http://www.aronsonimmigration.com/

11. Getting good J-1 candidates into your applicant pool • Make sure IHS and ANTHC Statewide Recruiting office is notified • Internet resources – LOTS of them! • Build relations with residency programs • Get referrals from current physicians • Coordinate with Alaska DHSS (Pat Carr and Triptaa Surve) • Add to any advertising and web postings

13. Typical J-1 Waiver Concerns • Can the international physician speak English? • Can he/she communicate with and work with staff? • Can he/she communicate with our Elders? • Will he/she fit in with the local community? • Are international physicians high quality doctors? • What can I do if they don’t work out? • Do J-1 waivers conflict with Native preference, the Alaska Family Medicine Residency, or WWAMI? • Wow, this is a lot of paperwork—is it worth it?

14. Benefits of J-1 Waivers • PATIENT CARE: Better physician supply = better access and quality of care • LABOR POOL: International physicians have few options to stay in U.S. • QUALITY: Physicians must have completed U.S. medical residency • OPTIONS: Facilities can use all the usual recruiting / screening tools • STABILITY: Physician employment contract must be for at least 3 yrs • MOBILITY: Physician may work at other HPSA sites during 3 yrs • SAVINGS: Physician “prevailing wage,” may be less than locum costs • SUSTAINABILITY: More physicians = better ability to meet customer-owner demand for medically necessary services that are reimbursable.

15. Indian Health Service 2008Alaska Reimbursement Rates • Outpatient per visit Medicaid ........ $423 (payment is 100% federal, 0% state) • Outpatient per visit Medicare......... $365 (payment is 100% federal, 0% state) • Inpatient hospital per diem ......... $2,255 (not including physician services) (payment is 100% federal, 0% state)