Mary E. Ryan

 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

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) ,100706,5007,400None ,700723,40013,7004, ,600798,50062,90033, ,800851,30091,50046, ,400916,000130,60064,800 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

Specialties Internal Medicine % Pediatrics % Family Medicine6227.9% General Surgery5667.2% Psychiatry4125.2% Neurology3244.1% Obstetrics1511.9% Orthopaedic Surgery1131.4% Diagnostic Radiology1081.4% Anesthesiology1041.2% IMG 2013: citing ECFMG (2102) 2011 Annual Report

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 programs26.3* % IMGs in patient care % office/20.4% Hospital % IMGs on full-time staff29.9 % IMGs in research19.9 % IMGs in medical teaching16.7* % IMGs in administration12.0 * Percentages exclude residents/fellows. IMG 2013 Citing Source: AAMC Center for Workforce Studies, June 2010

Positions offered2,7082,6082,5352,6032,7112,761 Positions filled2,5551,1692,3111,3702,2992,307 % filled94.0%91.4%91.2%90.6%88.3%85.0% Filled by U.S. seniors 1,3011,1691,0711,1561,0961,123 % filled by U.S. seniors 48.0%44.8%42.2%43.9%42.1%41.4% IMG 2013 citing National Resident Matching Program

 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

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

 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

 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

 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

 Subject to spouse’s 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

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

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

 Generally for all IGA programs ◦ Worksite(s) in Federally designated medically underserved areas – HPSA/MUA  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

 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

 Applications require: ◦ 6 months of evidence of unsuccessful recruitment ◦ Evidence of facility’s patient mix:  Commercially insured  Medicaid/Medicare  Sliding Fee ◦ Public notice that all patients will be seen regardless of ability to pay

 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

 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

◦ 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

 Change of start date  Change of salary  Change of practice site  Performance

 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

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

 /law-and-policy/bulletin.html /law-and-policy/bulletin.html Employm ent- based AllChina – Mainland IndiaMexicoPhilippin es 1 st CCCCC 2 nd CNov 15, 2009 May 01, 2009 CC 3edOct 1, 2011 April 1, 2009 Nov 15, 2003 Oct 1, 2011

 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

 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

 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

 “Immigration law is a mystery and a mastery of obfuscation...” -USCIS spokeswoman Karen Kraushaar

Mary E. Ryan Taylor & Ryan, LLC 1777 Reisterstown Road, Ste. 265 Baltimore, MD