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Expert Advisers. Serving You. Providing Solutions You Need.

RECRUITMENT AND RETENTION TRAINING WORKSHOP J-1 Waiver Program by Robert D. Aronson October 13, 2011. Expert Advisers. Serving You. Providing Solutions You Need. 1. Immigration = tool to attract and retain talented Physicians. 2. Current Healthcare & Workforce Realities

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Expert Advisers. Serving You. Providing Solutions You Need.

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  1. RECRUITMENT AND RETENTION TRAINING WORKSHOPJ-1 Waiver Program byRobert D. Aronson October 13, 2011 Expert Advisers. Serving You. Providing Solutions You Need. 1

  2. Immigration = tool to attract and retain talented Physicians 2

  3. Current Healthcare & Workforce Realities A Look at the IMG Workforce Basic Immigration Overview General Recruitment Issues J-1 Physician Recruitment H-1B Physician Recruitment Permanent Residence STRUCTURE OF PRESENTATION Expert Advisers. Serving You. Providing Solutions You Need. 3

  4. BASIC GOAL OF PROGRAM Making Physician Immigration Work as Another Recruitment Tool 4

  5. RECRUITMENT AND RETENTION TRAINING WORKSHOP 5

  6. CURRENT HEALTHCARE & WORKFORCE REALITIES 6

  7. CURRENT HEALTHCARE REALITY: Pervasive shortage of physicians Inequalities in delivery system (geographic + compositional split) Grossly large healthcare expenditures (16.2% of GNP) 40 million uninsured (+20 million with unstable coverage) Healthcare reform: adds roughly 32 million additional patients to system Avoidance of healthcare rationing Expert Advisers. Serving You. Providing Solutions You Need. 7

  8. THEORIES OF PHYSICIAN COVERAGE Market Mechanisms to Govern Oversupply of Physicians Oversupply but Problems with: Geographic Distribution Practice (Primary Care vs. Specialty Care) Breakdown Widespread, Endemic Shortages Expert Advisers. Serving You. Providing Solutions You Need. 8

  9. PHYSICIAN SHORTAGE DIMENSIONS: By 2025: 124,000 (estimates vary: up to 312,000) Immediate need in underserved areas: 16,643 Expert Advisers. Serving You. Providing Solutions You Need. 9

  10. FACTORS IMPACTING SHORTAGE SITUATION Increase in demand (“death as an option”) Aging physician workforce Aging population having greater medical needs Gender & lifestyle considerations in workforce Corporate practice of medicine Expert Advisers. Serving You. Providing Solutions You Need. 10

  11. MORE FACTORS IMPACTING SHORTAGE SITUATION Expanding treatment capabilities Tort/liability/defensive medicine Cost of medical education Revisions to reimbursement patterns Alternative career options Expert Advisers. Serving You. Providing Solutions You Need. 11

  12. HEALTHCARE DELIVERY REFORM Increase physician workforce: funding of training slots (Resident Physician Shortage Reduction Act) Physician extenders (physician assistants, nurse practitioners, etc.) Efficiencies of service Expert Advisers. Serving You. Providing Solutions You Need. 12

  13. HEALTHCARE DELIVERY REFORM Preventive medical services Telemedicine Biomedical research Medical ethics: end-of-life issues Nontraditional pools of physicians (IMGs) Expert Advisers. Serving You. Providing Solutions You Need. 13

  14. NATIONAL J-1 WAIVER STATITSTICS 10 year period: 8264 2010 statistics: Primary Care: 396 Special Care: 373 Rural: 360 Non-Rural 368 Non Medically-Underserved: 119 Expert Advisers. Serving You. Providing Solutions You Need. 14

  15. NATIONAL TRENDS: Pretty steady utilization With increase in H-1B physicians, more possibilities for J-1 waiver placements Expert Advisers. Serving You. Providing Solutions You Need. 15

  16. A LOOK AT THE INTERNATIONALMEDICAL GRADUATE (IMG)WORKFORCE 16

  17. IMG: DEFINITION OF TERM Physician who has received medical degree outside the United States from non-accredited programs (that is, outside U.S. & Canada) Subset of IMG population is foreign national physicians Subset of foreign national physicians are those with visa needs Expert Advisers. Serving You. Providing Solutions You Need. 17

  18. DIMENSIONS OF IMG POPULATION: Roughly about 25% of physician workforce About 27.5% of GME population Expert Advisers. Serving You. Providing Solutions You Need. 18

  19. POOLS OF IMGs U.S. Citizens (30%) Permanent residents (26%) Refugees (0.3%) Temporary nonimmigrants (mainly, J-1 & H-1B) (30%) Other (14%) Expert Advisers. Serving You. Providing Solutions You Need. 19

  20. IMPORTANT POINT: U.S. IMMIGRATION POLICY CAN INDUCE DESIRABLE PRACTICE PATTERNS IN HARD-TO-FILL PLACEMENTS 20

  21. TOP PROVIDER COUNTRIES India (20%) Philippines Mexico Pakistan Dominican Republic Expert Advisers. Serving You. Providing Solutions You Need. 21

  22. IMG PRACTICE CHARACTERISTICS Expert Advisers. Serving You. Providing Solutions You Need. 22

  23. GAP-FILLING/SAFETY-NET PRACTICE PATTERNS IMGs tend to practice disproportionately in non-traditional practice settings Medically underserved areas Serve minority, immigrant, & underserved patient populations Clinical settings Primary care Improved quality standards Better community receptivity Expert Advisers. Serving You. Providing Solutions You Need. 23

  24. MOTIVATIONAL ELEMENTS Professional realities Competitive advantage Relocation flexibilities Immigration policy Expert Advisers. Serving You. Providing Solutions You Need. 24

  25. SPECIFIC PRACTICE PATTERNS Primary Care: 58% in primary care (vs. 26% USMGs) Practice Breakdown: Internal Medicine (37%) Psychiatry (32%) Pediatrics (28%) Anesthesiology (28%) Family Medicine (27%) OB/GYN (17%) Expert Advisers. Serving You. Providing Solutions You Need. 25

  26. SPECIFIC PRACTICE PATTERNS (CONT.) Direct Patient Care: Physician-Patient hours Greater % of owners or solo/two-physician practice groups Result: more hours/week, more patient contacts/week Less involvement in administration, medical research, teaching Expert Advisers. Serving You. Providing Solutions You Need. 26

  27. SPECIFIC PRACTICE PATTERNS (CONT.) Coverage of Medicare/Medicaid/SCHIP Patients Higher percentage of Medicare (67%) and Medicaid (49%) providers SCHIP providers (18% for IMGs vs. 10% USMGs) Expert Advisers. Serving You. Providing Solutions You Need. 27

  28. SPECIFIC PRACTICE PATTERNS (CONT.) Critical Access Hospitals Roughly 44% have at least 1 staff IMG Expert Advisers. Serving You. Providing Solutions You Need. 28

  29. SPECIFIC PRACTICE PATTERNS (CONT.) Racial/Ethnic Coverage Service to minority populations Increase in diversity in physician workforce Expert Advisers. Serving You. Providing Solutions You Need. 29

  30. SPECIFIC PRACTICE PATTERNS (CONT.) Coverage in Medically Underserved Areas Comprise roughly 40% of all inner-city physicians 68% of IMGs with temporary visa status in shortage areas J-1 physicians: 95% / H-1B physicians: 50% GAO study on retention patterns of J-1 physicians: 90%: complete 3-year term 33%: remain for 4 years 28%: remain for 5+ years Suspected reasons: J-1 Waiver National Interest Waiver Expert Advisers. Serving You. Providing Solutions You Need. 30

  31. SOME FUNDAMENTALS IN IMMIGRATION • BASIC CONCEPTS OF U.S. IMMIGRATION Expert Advisers. Serving You. Providing Solutions You Need. 31

  32. THREE (3) BASKETS OF LEGAL IMMIGRATION • Temporary, Nonimmigrant Status • Permanent Residence • U.S. Citizenship Expert Advisers. Serving You. Providing Solutions You Need. 32

  33. BASKET #1: TEMPORARY/NONIMMIGRANT STATUS • Basic Definition: • Temporary Period of Status • Limited Scope of Activity • Requires Sponsorship Expert Advisers. Serving You. Providing Solutions You Need. 33

  34. BASKET #1: TEMPORARY/NONIMMIGRANT STATUS • How to tell someone is in temporary status: • Letter-Number Combination: • J-1 Exchange Visitor • H-1B Temporary Worker • F-1 Student • TN Canadian or Mexican Professional • B-1 / B-2 Visitor Expert Advisers. Serving You. Providing Solutions You Need. 34

  35. BASKET #2: PERMANENT RESIDENCE • Right to Live and Work Indefinitely • Reentry Permission following Trips Abroad • Can be Lost Expert Advisers. Serving You. Providing Solutions You Need. 35

  36. BASKET #3: U.S. CITIZENSHIP • Constitutionally protected status subject to wide range of due process protections • Cannot be lost (except under rare circumstances) Expert Advisers. Serving You. Providing Solutions You Need. 36

  37. GENERAL RECRUITMENT ISSUES 37

  38. EMPLOYER HANDBOOK, M274 • Reviews anti-discrimination considerations • Reviews common I-9 questions • Important resource for employer responsiblities • http://www.uscis.gov/files/form/m-274.pdf Expert Advisers. Serving You. Providing Solutions You Need. 38

  39. ANTIDISCRIMINATION • Prevent discrimination based on citizenship, nationality, national origin, etc. • Puts limits on questions that can be asked during interview/recruitment process • Does NOT compel an employer to hire nonimmigrant Expert Advisers. Serving You. Providing Solutions You Need. 39

  40. I-9 EMPLOYMENT VERIFICATION • Must be completed for all new hires, regardless of immigration status • Needs to be completed within three days of employment start date • Need to have a consistent policy and practice for I-9 completion Expert Advisers. Serving You. Providing Solutions You Need. 40

  41. J-1 PHYSICIAN RECRUITMENT 41

  42. J-1 PHYSICIAN RECRUITMENT • J-1 Exchange Visitor Program • Two-year Home Residence Obligation • Basic Waiver Strategies: • North Dakota Department of Health • Department of Health and Human Services Expert Advisers. Serving You. Providing Solutions You Need. 42

  43. BASIC CHARACTERISTICS Temporary, nonimmigrant classification Cold War creation Purpose: to train and orient foreign elites for leadership role in home country Administered by U.S. Department of State Covers various activities in United States (14 broad categories) Expert Advisers. Serving You. Providing Solutions You Need. 43

  44. WHAT IS THE J-1 EXCHANGE VISITOR PROGRAM FOR PHYSICIANS? Authorizes Graduate Medical Education for up to seven years (longer for exceptional circumstances) Does not authorize: Moonlighting Employment (other than Training) Includes employment eligibility for spouse Admitted by ECFMG Expert Advisers. Serving You. Providing Solutions You Need. 44

  45. FUNCTIONS OF ECFMG Verifying credentials of IMGs Administering credentialing examinations Certifying IMGs for GME Administering the J-1 Program Expert Advisers. Serving You. Providing Solutions You Need. 45

  46. TWO YEAR HOME RESIDENCE OBLIGATION Every J-1 clinical physician trainee is obligated to return for two years to the home country or country of last residence Home residence obligation means: Ineligible for H-1B Visa Ineligible for Permanent Residence Expert Advisers. Serving You. Providing Solutions You Need. 46

  47. IF A PHYSICIAN IS SUBJECT TO THE TWO-YEAR HOME RESIDENCE OLIBGATION: Return home for two years J-1 Waiver Visa status other than H-1B and/or permanent residence (O-1, etc) But does not relieve two year obligation Expert Advisers. Serving You. Providing Solutions You Need. 47

  48. WAYS A PHYSICIAN CAN OBTAIN A J-1 WAIVER Exceptional hardship to U.S. or LPR anchor relative (i.e., spouse and/or child) Persecution in home country Sponsorship of Government Agency: Direct employment (U.S. Military or VA hospital) Outstanding research (HHS/NIH) Federal agency (DRC, ARC, HHS) State Department of Health (Conrad Waiver) Expert Advisers. Serving You. Providing Solutions You Need. 48

  49. INTERESTED GOVERNMENT AGENCIES (IGA) WAIVERS North Dakota Conrad Waiver Department of Health and Human Services Expert Advisers. Serving You. Providing Solutions You Need. 49

  50. WHAT IS A CONRAD WAIVER? Congressionally-created waiver program administered by state departments of health Creates 30 waivers: 10 waiver limit to non-designated worksites Balance to designated underserved areas (HPSA & MUA) 3 year H-1B Employment Obligation with Sponsoring Employer (Retention) Needs to be Employer Sponsored Expert Advisers. Serving You. Providing Solutions You Need. 50

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