1. 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) 2008699,100706,5007,400None 2010709,700723,40013,7004,700 2015735,600798,50062,90033,100 2020759,800851,30091,50046,100 2025785,400916,000130,60064,800 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

4. Specialties Internal Medicine360345.8% Pediatrics86111.0% 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 www.ecfmg.orgwww.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 programs26.3* % IMGs in patient care75.5 55.1% 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

6. 201120102009200820072006 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

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 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

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 facility’s 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/content/visas/english /law-and-policy/bulletin.html http://travel.state.gov/content/visas/english /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

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