Foreign Physicians: Data on Use of J-1 Visa Waivers Needed to Better Address Physician Shortages
Published: 2006-11-30T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Many U.S. communities face difficulties attracting physicians. To address this problem, states and federal agencies have turned to foreign physicians who have just completed graduate medical education in the United States under J-1 visas. Ordinarily, these physicians must return home after completing their programs, but this requirement can be waived at the request of a state or federal agency if the physician agrees to practice in an underserved area. In 1996, GAO reported that J-1 visa waivers had become a major source of physicians for underserved areas but were not well coordinated with Department of Health and Human Services (HHS) programs for addressing physician shortages. GAO was asked to examine (1) the number of waivers requested by states and federal agencies; (2) waiver physicians' practice specialties, settings, and locations; and (3) the extent to which waiver physicians are accounted for in HHS's efforts to address physician shortages. GAO surveyed states and federal agencies about waivers they requested in fiscal years 2003-2005 and reviewed HHS data.
section_title: What GAO Found
paragraphs: The use of J-1 visa waivers remains a major means of providing physicians to practice in underserved areas of the United States. More than 1,000 waivers were requested in each of fiscal years 2003 through 2005 by states and three federal agencies--the Appalachian Regional Commission, the Delta Regional Authority, and HHS. At the end of fiscal year 2005, the estimated number of physicians practicing in underserved areas through J-1 visa waivers exceeded the number practicing there through the National Health Service Corps (NHSC)--HHS's primary mechanism for addressing physician shortages. In contrast to a decade ago, when federal agencies requested the vast majority of waivers, states have become the primary source of J-1 visa waiver requests, accounting for 90 percent or more of waiver requests in fiscal years 2003 through 2005. States and federal agencies requested waivers for physicians to work in a variety of practice specialties, settings, and locations. In fiscal year 2005, a little less than half of the waiver requests were for physicians to practice exclusively primary care. More than three-quarters of the waiver requests were for physicians to work in hospitals or private practices, and about half were for physicians to practice in rural areas. HHS does not have the information needed to account for waiver physicians in its efforts to address physician shortages. Without such information, when considering where to place NHSC physicians, HHS has no systematic means of knowing if an area's needs are already being met by waiver physicians.

section_title: Letter
paragraphs: Many communities throughout the country experience difficulties in  attracting physicians to meet their health care needs. To address the need  for physicians in underserved areas, states and federal agencies have  turned to foreign physicians who have just completed their graduate  medical education in the United States. Many of these foreign physicians  entered the United States on temporary visas, called J-1 visas. Once they  have completed their graduate medical education, these physicians are  required to return to their home country or country of last legal residence  for at least 2 years before they may apply to stay permanently in the  United States or for certain temporary work visas. This foreign residence  requirement can, however, be waived in certain circumstances, including  at the request of a state or federal agency if the physician agrees to  practice in an underserved area for at least 3 years. J-1 visa waivers are  granted by the Department of Homeland Security at the recommendation  of the Department of State.
In 1996, we reported that the number of J-1 visa waivers requested by  states and federal agencies for physicians to work in underserved areas  had risen dramatically—from 70 in 1990 to more than 1,300 in 1995—and  that requesting waivers had become a major means of placing physicians  in underserved areas. We estimated that in 1995, the number of waiver  physicians practicing in underserved areas exceeded the number of  physicians practicing in such areas through National Health Service Corps  (NHSC) programs—the Department of Health and Human Services’ (HHS)  primary mechanism for addressing shortages of physicians and other  primary care health professionals. We reported that slightly over half of  these waiver physicians practiced internal medicine and that nearly   40 percent of them practiced in nonprofit community or migrant health  centers. Further, we noted that controls for ensuring that these physicians  met the terms of their waiver agreements were somewhat weak, and we  found cases in which physicians were not meeting their waiver  agreements, such as not practicing at the facilities or in the underserved  areas for which the physicians’ waivers were granted. Finally, we reported  that the use of waivers was not effectively coordinated with HHS  programs addressing underservice, such as NHSC programs. As a result,  some states had more physicians than HHS identified as needed to  alleviate shortages, while other states were still experiencing shortages.
You expressed an interest in how J-1 visa waivers are being used to place  physicians in underserved areas. In May 2006, we testified on preliminary  findings from our work, focusing primarily on states’ requests for J-1 visa  waivers. This report provides information on both states’ and federal  agencies’ J-1 visa waiver requests and addresses (1) the number of waivers  requested by states and federal agencies in fiscal years 2003 through 2005;  (2) the practice specialties, settings, and locations in which waiver  physicians work; (3) the activities states and federal agencies undertake to  help ensure that physicians are meeting their agreements to work in  underserved areas; and (4) the extent to which waiver physicians are  accounted for in HHS’s efforts to address physician shortages.
To address these issues, we administered a Web-based survey to the  entities eligible to request J-1 visa waivers under the authority granted to  the states: the 50 states, the District of Columbia, Guam, Puerto Rico, and  the U.S. Virgin Islands (hereafter referred to as “states”). We also  surveyed the three federal agencies that requested waivers for physicians  to practice in underserved areas in fiscal years 2003 through 2005—the  Appalachian Regional Commission (ARC), the Delta Regional Authority  (DRA), and HHS—using a structured data collection instrument. We sent  the surveys to the officials in each state or federal agency authorized to  sign waiver requests or to his or her designee. The surveys asked each  state and federal agency to provide information on the number of waivers  requested in each of fiscal years 2003 through 2005; the practice  specialties, settings, and locations of physicians for whom waivers were  requested; the state’s or federal agency’s policies for requesting waivers;  activities undertaken to help ensure that waiver physicians are meeting  their agreements to work in underserved areas; and incidents in which  physicians were not meeting their waiver agreements. The response rate  to both surveys was 100 percent. We reviewed the survey responses for  internal consistency and for outliers, and we followed up with respondents  to resolve discrepancies and clarify responses; we did not, however, verify  the accuracy of the responses. Regarding federal agencies’ J-1 visa waiver  programs, we interviewed officials from ARC, DRA, and HHS and obtained  from them data on their waiver requests by state. We reviewed states’ and  federal agencies’ policies and guidelines pertaining to their J-1 visa waiver  programs as of September 30, 2005; reviewed relevant laws, regulations,  and documents; and interviewed officials involved in recommending and  granting waivers at the Department of State and the Department of  Homeland Security.
To examine how the use of J-1 visa waivers is accounted for in HHS’s  efforts to address physician shortages, we interviewed officials from  HHS’s Health Resources and Services Administration and obtained from  them data on the number of NHSC physicians practicing in each state and  the number of physicians needed to remove shortage designations in each  state as of September 30, 2005. We estimated the number of waiver  physicians practicing primary care in each state as of September 2005,  using states’ and federal agencies’ responses to our survey. (See app. I for  detailed information on this analysis.) In addition, we interviewed officials  at the Educational Commission for Foreign Medical Graduates (ECFMG),  the organization that sponsors foreign physicians as exchange visitors for  graduate medical education. We conducted our work from August 2005  through November 2006 in accordance with generally accepted  government auditing standards.
subsections: section_title: Background
paragraphs: Many foreign physicians who enter U.S. graduate medical education  programs do so as participants in the Department of State’s Exchange  Visitor Program—an educational and cultural exchange program aimed at  increasing mutual understanding between the peoples of the United States  and other countries. Participants in the Exchange Visitor Program enter  the United States with J-1 visas. Nearly 6,200 foreign physicians with J-1  visas took part in U.S. graduate medical education programs during  academic year 2004–05.
Physicians participating in graduate medical education on J-1 visas are  required to return to their home country or country of last legal residence  for at least 2 years before they may apply for an immigrant visa, permanent  residence, or certain nonimmigrant work visas. They may, however,  obtain a waiver of this requirement from the Department of Homeland  Security at the request of a state or federal agency if they have agreed to  practice in an underserved area for at least 3 years. States were first  authorized to request J-1 visa waivers on behalf of foreign physicians in  October 1994. Federal agencies were first authorized to request J-1 visa  waivers for physicians in graduate medical education in September 1961.
In general, waiver physicians must practice in areas that HHS has  designated as underserved. HHS has specified that waiver physicians may  practice in HPSAs or medically underserved areas or populations  (MUA/P). HPSAs are geographic areas, population groups within areas,  or facilities that HHS has designated as having a shortage of health  professionals; HPSAs for primary care are generally identified on the basis  of the ratio of population to primary care physicians and other factors.
MUA/Ps are areas or populations that HHS has designated as having  shortages of health care services; these are identified using several factors  in addition to the ratio of population to primary care physicians. HPSAs  and MUA/Ps can overlap; as a result, a facility can be located in both a  HPSA and an MUA/P.
States and federal agencies have some discretion in shaping their J-1 visa  waiver programs to address particular needs or priorities. For example,  while states and federal agencies can request waivers for physicians to  work in both primary care and nonprimary care specialties and in a variety  of practice settings, they may choose to limit the number of waivers they  request for physicians to practice nonprimary care or require that waiver  physicians work in certain practice settings. States and federal agencies  may also choose to conduct monitoring activities to help ensure that  physicians are meeting their waiver agreements—for example, that they  are working at the facilities for which their waivers were granted.
Although states and federal agencies are generally subject to the same  statutory provisions regarding requests for J-1 visa waivers for physicians,  there are two notable distinctions. First, states are limited in the number  of waivers that may be granted in response to their requests each year.  Initially, states were authorized to request waivers for up to 20 physicians  each fiscal year; in 2002, the limit was increased to 30 waivers per state per  year. Federal agencies are not statutorily limited in the number of waivers  that may be granted in response to their requests each year. Second, while  federal agencies’ waiver requests must be for physicians to practice in  underserved areas, Congress gave states the flexibility, in December 2004,  to use up to 5 of their 30 waiver allotments each year for physicians to  work in facilities located outside of HHS-designated undeserved areas,  provided that the facilities treat patients who reside in underserved areas.  We refer to these waivers as “flexible waivers.”
Obtaining a J-1 visa waiver at the request of a state or federal agency to  practice in an underserved area involves multiple steps (see fig. 1). A  physician must submit an application to obtain a case number from the  Department of State and must secure a bona fide offer of employment  from a health care facility that is located in an underserved area or, in the  case of flexible waivers, from a health care facility that treats residents of  an underserved area. The physician, the prospective employer, or both  apply to a state or federal agency to request a waiver on the physician’s  behalf. If, after reviewing the application, the state or federal agency  decides to request a waiver, the state or federal agency submits a letter of  request to the Department of State affirming that it is in the public interest  for the physician to remain in the United States. If the Department of State  decides to recommend the waiver, it forwards its recommendation to the  Department of Homeland Security’s U.S. Citizenship and Immigration  Services (USCIS). USCIS is responsible for making the final determination  and notifying the physician when the waiver is granted. According to  officials involved in recommending and approving waivers at the  Department of State and USCIS, after a review for compliance with  statutory requirements and security issues, nearly all waiver requests are  recommended and granted. Once the physician is granted the waiver, the  employer petitions USCIS for the physician to obtain H-1B status (a  nonimmigrant classification used by foreign nationals employed  temporarily in a specialty occupation). The physician must work at the  facility specified in the waiver application for a minimum of 3 years, unless  the physician obtains approval from USCIS to transfer to another facility.  USCIS considers transfer requests only in extenuating circumstances, such  as closure of the physician’s assigned facility. Once the physician fulfills  the employment contract, the physician may apply for permanent  residence, continued H-1B status, or other nonimmigrant status, if the  physician wishes to remain in the United States.
No single federal agency is responsible for managing or tracking the use of  J-1 visa waivers for physicians to practice in underserved areas. HHS is the  primary federal agency responsible for addressing physician shortages,  both in terms of administering NHSC programs that place physicians and  other providers in areas experiencing shortages of health professionals  and in designating areas as underserved. HHS’s oversight of waiver  physicians practicing in underserved areas, however, has generally been  limited to the few physicians for whom it has requested J-1 visa waivers.  USCIS and the Department of State process J-1 visa waiver requests but do  not maintain comprehensive information about waiver physicians’  numbers, practice locations, and practice specialties. States and federal  agencies that request waivers maintain such information for the physicians  for whom they request waivers, but this information is not centrally  collected and maintained by any federal agency.
Although the use of J-1 visa waivers has not been systematically tracked,  available data indicate that the pool of physicians who could seek  waivers—that is, the number of foreign physicians in graduate medical  education with J-1 visas—has declined in recent years. In academic year  1996–97, a little more than 11,600 foreign physicians took part in U.S.  graduate medical education programs with J-1 visas; by academic year  2004–05 this number had decreased more than 45 percent to slightly less  than 6,200. The reasons for this decrease are not completely understood.
section_title: Waivers Remain a Major Means for Providing Physicians to Underserved Areas
paragraphs: States and federal agencies reported requesting more than 1,000 J-1 visa  waivers in each of fiscal years 2003 through 2005 (see fig. 2). We  estimated that, at the end of fiscal year 2005, there were roughly one and a  half times as many waiver physicians practicing in underserved areas  (3,128) as U.S. physicians practicing in underserved areas through NHSC  programs (2,054).
In contrast to our findings a decade ago, states have become the primary  source of waiver requests for physicians to practice in underserved areas,  accounting for 90 percent or more of requests in each of fiscal years 2003  through 2005. The number of states that reported ever having requested a  J-1 visa waiver has grown steadily since they were first authorized to do  so, from 20 states in fiscal year 1995 to 53 states (all but Puerto Rico) as of  fiscal year 2005. States varied, however, in the number of waivers they  requested in fiscal years 2003 through 2005. For example, in fiscal year  2005, about one-quarter of the 54 states requested the maximum of 30  waivers, about one-quarter requested 10 or fewer, and two (Puerto Rico  and the U.S. Virgin Islands) requested no waivers (see fig. 3).
The number of waivers requested by federal agencies has decreased  significantly since 1995, with the exit of the two agencies that requested  the most waivers for physicians to practice in underserved areas that year.  The Department of Agriculture, which stopped requesting waivers for  physicians to practice in underserved areas in 2002, and the Department of  Housing and Urban Development, which stopped in 1996, together  requested more than 1,100 waivers for physicians to practice in 47 states in  1995, providing a significant source of physicians for some states. Federal  agencies accounted for about 94 percent of waiver requests that year, in  contrast to fiscal year 2005, when federal agencies made about 6 percent  of requests. Of the 1,012 waivers requested by states and federal agencies  in fiscal year 2005, ARC, DRA, and HHS accounted for 56 requests for  physicians to practice in 14 states.
section_title: Waivers Were Requested for Physicians to Work in a Variety of Practice Specialties, Settings, and Locations
paragraphs: States and federal agencies requested waivers for physicians to practice a  variety of specialties, with states requesting waivers for physicians to  practice both primary and nonprimary care and federal agencies generally  focusing on primary care. Although the waivers states and federal agencies  requested were for physicians to work in diverse practice settings, most  were for physicians to work in hospitals and private practices. These  practice settings were about equally divided between rural and nonrural  areas. Additionally, less than half of the states opted to request flexible  waivers for physicians to work outside of designated underserved areas.
Overall, a little less than half (46 percent) of the waivers requested by  states and federal agencies in fiscal year 2005 were for physicians to  practice exclusively primary care, while a slightly smaller proportion   (39 percent) were for physicians to practice exclusively nonprimary care  (see fig. 4). A small proportion of waiver requests (5 percent) were for  physicians to practice both primary and nonprimary care—for example,  for individual physicians to practice both internal medicine and  cardiology. An additional 7 percent of waiver requests in fiscal year 2005  were for physicians to practice psychiatry.
States and federal agencies differed, however, in the proportion of waivers  they requested for physicians to practice primary versus nonprimary care  (see fig. 5). Less than 50 percent of the waivers requested by states in  fiscal year 2005 were for physicians to practice exclusively primary care,  compared with 80 percent of those requested by federal agencies.
Nearly all of the states and DRA reported that their fiscal year 2005  policies allowed them to request waivers for physicians to practice  nonprimary care. Twenty-seven of these states, however, reported  placing some limits on such requests, including limiting the number of  requests for physicians to practice nonprimary care or restricting the  number of hours a physician could practice a nonprimary care specialty.  Even with these limitations, the number of waivers requested for  physicians to practice nonprimary care increased among both states and  federal agencies over the 3-year period beginning in fiscal year 2003.
Overall, requests for physicians to practice exclusively nonprimary care  increased from about 300 (28 percent) in fiscal year 2003 to nearly 400   (39 percent) in fiscal year 2005. States and federal agencies reported  requesting waivers in fiscal year 2005 for physicians to practice more than  40 nonprimary care specialties (e.g., anesthesiology) and subspecialties  (e.g., pediatric cardiology); the most common of these were  anesthesiology, cardiology, and pulmonology (the study and treatment of  respiratory diseases).
Regarding practice settings, more than three-quarters of the waivers  requested by states in fiscal year 2005 were for physicians to practice in  hospitals (37 percent) and private practices (41 percent) (see fig. 6). In  addition, 16 percent were for physicians to practice in federally qualified  health centers (facilities that provide primary care services in underserved  areas) and rural health clinics (facilities that provide outpatient primary  care services in rural areas). Although the largest proportion of waivers  that states requested was for physicians to work in private practices, more  than 80 percent of the states and all three federal agencies reported that  their fiscal year 2005 policies required the facilities where waiver  physicians work—regardless of practice setting—to accept some patients  who are uninsured or covered by Medicaid.
Overall, about half of all waiver requests in fiscal year 2005 were for  physicians to practice in areas that respondents considered rural, although  the proportions differed between states’ and federal agencies’ requests.  States’ waiver requests in fiscal year 2005, which accounted for the vast  majority of total requests that year, were about equally divided between  those for physicians to work in areas respondents considered rural and  those they considered nonrural. Federal agencies’ waiver requests were  mostly (93 percent) for physicians to work in areas considered rural (see  fig. 7).
Most of the waivers requested by states and federal agencies in fiscal year  2005 were for physicians to practice in HPSAs. While federal regulations  generally permit states and federal agencies to request waivers for  physicians to work in HPSAs or MUA/Ps, about a quarter of the states and  two federal agencies (ARC and HHS) had policies in place in fiscal year  2005 that limited at least some types of physicians to practicing in HPSAs.  Overall, more than three-quarters (77 percent) of waivers requested by  states and federal agencies in fiscal year 2005 were for physicians to work  in facilities located in HPSAs, and 16 percent were for physicians to work  in facilities located in MUA/Ps that were outside of HPSAs. Additionally,  less than half of the states (23 states) reported taking advantage of the  option to request flexible waivers—those for physicians to work in  facilities that, while located outside of HHS-designated underserved areas,  treat patients residing in underserved areas. Requests for flexible waivers  in fiscal year 2005, the first year such waivers were allowed, accounted for  7 percent of all waiver requests that year.
section_title: Most States and Federal Agencies Reported That They Conducted Monitoring Activities
paragraphs: Most states and federal agencies reported that they conducted monitoring  activities to help ensure that physicians were meeting their agreements to  work in underserved areas. Although monitoring is not explicitly required  of states and federal agencies that request waivers, more than 85 percent  of states and two of the three federal agencies that requested waivers in  any fiscal year from 2003 through 2005 reported that they conducted at  least one monitoring activity in fiscal year 2005. These activities included  actions to help determine, for example, whether physicians were working  in the locations for which their waivers were requested or whether they  were treating the intended patients, such as those who were uninsured or  covered by Medicaid. The most common monitoring activity—reported by  40 states, ARC, and DRA—was to require periodic reports from physicians  or employers (see fig. 8). For example, some states and federal agencies  required written reports submitted once or twice a year that included  information such as the number of hours waiver physicians worked or the  number of patients for whom Medicaid claims were submitted. States and  federal agencies that requested waivers also reported that they monitored  waiver physicians through regular communications with employers and  physicians, such as through phone calls, and through site visits to waiver  physicians’ practice locations. In addition, a small number of states  reported conducting other monitoring activities. For example, one state  official said the state’s J-1 visa waiver program used Medicaid data to  confirm that waiver physicians were treating patients covered by  Medicaid.
Although most states and federal agencies reported conducting at least  one monitoring activity, the number of monitoring activities varied. Ten  states and DRA reported conducting at least four different activities, while  six states and HHS—together accounting for about 13 percent of waiver  requests in fiscal year 2005—reported that they did not conduct any  monitoring activities in fiscal year 2005. Four of the six states that  reported they did not conduct monitoring activities reported requesting  more than 25 waivers in each of fiscal years 2003 through 2005.
States and federal agencies reported identifying relatively few incidents in  fiscal years 2003 through 2005 in which physicians were not meeting their  waiver agreements. These incidents included cases in which the  physician was not working in the practice specialty or at the facility  specified in his or her waiver agreement, was not seeing the intended  patients, or did not serve the entire 3-year employment contract. The most  common issue cited was physicians’ transferring to another location or  employer without the approval of the state or federal agency that  requested their waivers. In addition, several states reported that they had  identified cases in which waiver physicians never reported to work.  Officials from these states cited examples in which physicians simply  failed to appear at the practice sites and did not contact the state that had  made the waiver requests on the physicians’ behalf. According to states  and federal agencies that reported identifying any incidents, physicians  were not solely responsible in all cases in which they did not meet their  waiver agreements. Some state officials provided examples of employers  who directed physicians to work in locations other than those for which  their waivers were requested, including locations outside of underserved  areas.
States and federal agencies that requested waivers reported that they use a  variety of practices to prevent or respond to cases of physicians’ not  meeting their waiver agreements (see fig. 9). For example, 38 states and  HHS reported that it is their practice to bar employers who are responsible  for problems involving waiver physicians from consideration for future J-1  visa waiver physician placements, either temporarily or permanently.  Forty states and two federal agencies reported that it is their practice to  inform USCIS if they identify physicians who are not meeting their waiver  agreements. Physicians not meeting their waiver agreements would again  be subject to the 2-year foreign residence requirement and would need to  return to their home country or country of last legal residence before they  could apply for an immigrant visa, permanent residence, or certain  nonimmigrant work visas. USCIS officials said that reports of physicians  not meeting their waiver agreements have been relatively rare. Some  states and federal agencies that requested waivers also reported that they  require physicians’ contracts to stipulate fees to be imposed if the  physicians fail to meet their waiver agreements. These requirements  include, for example, liquidated damages clauses, which set a particular  amount that physicians agree to pay employers if the physicians break  their employment contracts. Other practices that states reported included  reporting problems with waiver physicians to state medical boards.
States cited a number of factors affecting their ability to monitor or take  other actions that they believed could help them ensure that physicians  meet their waiver agreements. More than one-quarter of the states  reported that funding and staffing constraints limited their ability to carry  out monitoring activities. For example, four states commented that time  and staff constraints limited their ability to conduct visits to physicians’  practice sites. Several states noted that they have little or no authority to  take actions that would help ensure that physicians meet their waiver  agreements. For example, one state commented that beyond reporting  physicians who do not meet their waiver agreements to USCIS, it has no  authority over waiver physicians. In addition, a few states noted that their  ability to effectively monitor physicians is limited by the fact that they are  not notified when USCIS grants waivers or approves transfers.  Consequently, states may not know with certainty which physicians USCIS  has authorized to work in, or move to or from, their states. One federal  agency (ARC) cited two factors that positively affected its ability to help  ensure that physicians meet their waiver agreements: the liquidated  damages clauses for violating employment agreements that ARC requires  to be in physicians’ employment contracts, and site visits by staff of ARC’s  Office of Inspector General. According to a senior ARC official, these  unannounced visits have occasionally resulted in the discovery of  physicians working at sites other than those at which the physicians were  authorized to work. The official commented that the visits have also had a  deterrent effect.
section_title: HHS Lacks Data to Account for Waiver Physicians in Its Efforts to Address Physician Shortages
paragraphs: Although the use of J-1 visa waivers remains a major means of providing  physicians to practice in underserved areas, HHS does not have the  information needed to account for waiver physicians in its efforts to  address physician shortages. Without such information, when considering  where to place NHSC physicians, HHS has no systematic means of  knowing whether the needs of a HPSA are already being met through  waiver physicians. Our analysis indicates that some states could have had  more waiver and NHSC physicians practicing primary care in HPSAs than  HHS identified as needed, while other states were below HHS’s identified  need. Although data were not available to determine the number of waiver  physicians practicing primary care specifically in HPSAs, our analysis  showed that in seven states the estimated number of waiver physicians  practicing primary care in all locations (including HPSAs, MUA/Ps, and  nondesignated areas), combined with the number of NHSC physicians  practicing primary care in HPSAs at the end of fiscal year 2005, exceeded  the number of physicians HHS identified as needed to remove the primary  care HPSA designations in the state. In six of these seven states, the  estimated number of primary care waiver and NHSC physicians exceeded  by at least 20 percent the number needed to remove primary care HPSA  designations. Meanwhile, in each of 25 states, the estimated number of  primary care waiver and NHSC physicians was less than half of the state’s  identified need for primary care physicians.
The lack of information on waiver physicians could also affect HHS’s  efforts to revise how it designates primary care HPSAs and other  underserved areas. Multiple federal programs use HHS’s primary care  HPSA designation system to allocate resources or provide benefits, but as  we have reported, the designation system does not account for all primary  care providers practicing in underserved areas, including waiver  physicians. Specifically, waiver physicians practicing primary care in an  area are not counted in the ratio of population to primary care physicians,  one of the factors used to determine whether an area may be designated as  a primary care HPSA. HHS has been working on a proposal—in process  since 1998—to revise the primary care HPSA designation system, which  would, among other things, account for waiver physicians, according to  HHS officials. HHS officials acknowledged, however, that the department  lacked complete data on waiver physicians, needed to implement such a  provision.
Recognizing the lack of a comprehensive database with information on J-1  visa waiver physicians and other international medical graduates, HHS in  2003 contracted with ECFMG—the organization that sponsors all foreign  physicians with J-1 visas participating in graduate medical education—to  assess the feasibility of developing a database that would provide access  to information on the U.S. practice locations of, populations served by,  and other information about international medical graduates. ECFMG  completed the study and in 2004 submitted a draft report to HHS that  included recommendations. As of September 2006, a final report had not  been published.
section_title: Conclusions
paragraphs: The use of J-1 visa waivers remains a major means of placing physicians in  underserved areas of the United States, supplying even more physicians to  these areas than NHSC programs. Although thousands of physicians  practice in underserved areas through the use of J-1 visa waivers,  comprehensive data on their overall numbers, practice locations, and  practice specialties are not routinely collected and maintained by HHS.  Only by surveying states and federal agencies that requested waivers were  we able to collect information for this report. Having comprehensive data  on waiver physicians could help HHS more effectively target the  placement of NHSC physicians and implement proposed changes to  designating underserved areas.
section_title: Recommendation for Executive Action
paragraphs: To better account for physicians practicing in underserved areas through  the use of J-1 visa waivers, we recommend that the Secretary of Health  and Human Services collect and maintain data on waiver physicians— including information on their numbers, practice locations, and practice  specialties—and use this information when identifying areas experiencing  physician shortages and placing physicians in these areas.
section_title: Agency Comments and our Evaluation
paragraphs: We provided a draft copy of this report to the five federal agencies that are  involved with waivers for physicians to practice in underserved areas:  ARC, DRA, HHS, the Department of Homeland Security, and the  Department of State. We received written comments on the draft report  from HHS (see app. III). HHS concurred with our recommendation that  data should be collected and maintained to track waiver physicians. HHS  noted that the department had also discussed, internally, tracking other  physicians who are working under H-1B visas, stating that this would  allow a more complete accounting of the actual number of physicians  providing care in underserved areas. HHS commented that the  department’s goal is to assure that the limited resources of the J-1 visa  waiver program and other programs addressing areas and populations  with limited access to health care professionals are targeted most  effectively and that the availability of complete data on these additional  providers would enhance the data used to identify such shortage areas.
HHS also commented that the draft report may have overstated, to a  degree, the “oversupply” of physicians in some states. HHS acknowledged  that we made important adjustments in our analysis for physicians  practicing nonprimary care and psychiatry. The department, however,  expressed concern that our calculations did not address the fact that some  J-1 visa waiver placements are not in HPSAs, referring to our finding that   23 percent of waivers requested in fiscal year 2005 were for physicians to  practice outside of HPSAs. We believe that applying this percentage to our  analysis would be inappropriate for several reasons. First, this percentage  pertained to waiver physicians practicing all specialties, including primary  care, nonprimary care, and psychiatry, while our analysis focused on  physicians practicing primary care. Further, the 23 percent figure  represents waivers requested in only one fiscal year (fiscal year 2005),  while our analysis covered waivers requested in 3 fiscal years. In addition,  fiscal year 2005 was the only year in our analysis in which states could  request waivers for physicians to practice in nondesignated areas. In our  draft report, we did not use the term “oversupply,” but we acknowledge  that our report should clearly specify the limitations in the data used in  our analysis. To do so, we clarified the text describing our methodology  and results.
We also received technical comments from HHS and the Department of  Homeland Security’s USCIS, which we incorporated as appropriate. Three  agencies—ARC, DRA, and Department of State—said that they did not  have comments on the draft report.
We are sending copies of this report to the Secretary of Health and Human  Services, the Secretary of Homeland Security, the Secretary of State, the  Federal Co-chair of ARC, the Federal Co-chairman of DRA, and  appropriate congressional committees. We will also provide copies to  others upon request. In addition, the report is available at no charge on the  GAO Web site at http://www.gao.gov.
If you or your staff members have any questions about this report, please  contact me at (312) 220-7600 or aronovitzl@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on the  last page of this report. GAO staff who made major contributions to this  report are listed in appendix IV.
section_title: Appendix I: Physician Need and Number of Primary Care Waiver and National Health Service Corps Physicians, by State
paragraphs: This appendix presents the following information for each state as of the  end of fiscal year 2005: (1) the number of primary care physicians the  Department of Health and Human Services (HHS) identified as needed to  remove primary care health professional shortage area (HPSA)  designations, (2) our estimate of the number of J-1 visa waiver physicians  practicing primary care, (3) the number of National Health Service Corps  (NHSC) physicians practicing primary care, and (4) primary care waiver  and NHSC physicians as a percentage of the HHS-identified need.
To determine the need for primary care physicians in each state, we used  the number of physicians HHS reported as needed to remove primary care  HPSA designations in the state, a measurement used by HHS to identify  the need for physicians. Specifically, we used summary data from HHS’s  Health Resources and Services Administration on the number of additional  full-time equivalent (FTE) primary care physicians needed to remove  primary care HPSA designations in the state as of September 30, 2005.  HHS determines the number of additional full-time primary care  physicians needed to remove primary care HPSA designations for  geographic areas, population groups, and facilities. For geographic areas,  HHS’s threshold for the ratio of population to primary care physicians is  3,500 to 1 (or 3,000 to 1 under special circumstances); for population  groups, it is 3,000 to 1; for facilities that are state or federal correctional  institutions, it is 1,000 to 1. In calculating the ratio of population to  primary care physicians, HHS does not take into account waiver  physicians and most NHSC physicians. In addition to HPSAs, waiver  physicians may also practice in designated medically underserved areas or  populations (MUA/P). HHS does not, however, have a similar measure of  the number of physicians needed in MUA/Ps.
To determine the number of NHSC physicians practicing primary care in  HPSAs in each state as of September 30, 2005, we used data obtained from  the Health Resources and Services Administration on the number of  primary care physicians practicing through the NHSC Scholarship, NHSC  Loan Repayment, and NHSC Ready Responder programs. NHSC  physicians are required to practice in HPSAs.
Although data are not available on the number of physicians granted J-1  visa waivers and practicing primary care in underserved areas at any given  time, we estimated this number using data on waivers requested by states  and by three federal agencies—the Appalachian Regional Commission  (ARC), the Delta Regional Authority (DRA), and HHS. We estimated the  number of waiver physicians practicing primary care in each state as of   September 30, 2005, by using the number of waivers requested in fiscal  years 2003 through 2005 for such physicians. This number represents the  number of primary care physicians expected to be fulfilling the minimum  3-year employment contract at the end of fiscal year 2005 or who had  waivers in process to do so. Our estimate includes all waiver physicians  practicing primary care in the state (including those practicing in HPSAs,  MUA/Ps, and nondesignated areas). Data were not available to distinguish  waiver physicians practicing primary care in HPSAs from those practicing  in MUA/Ps or nondesignated areas.
Table 1 shows the estimated number of waiver and NHSC physicians  practicing primary care at the end of fiscal year 2005 and the number of  physicians needed to remove primary care HPSA designations in each  state.
section_title: Appendix II: States’ and Federal Agencies’ Requests for J-1 Visa Waivers
paragraphs: This appendix summarizes states’ and federal agencies’ responses to  selected questions from GAO’s surveys, as well as data obtained from  ARC, DRA, and HHS on their waiver requests by state. The following  tables present data on the number of waivers states and federal agencies  requested in each of fiscal years 2003 through 2005, in total (table 2), by  federal agency (table 3), by practice specialty (table 4), and by practice  setting (table 5). We also present data on states’ and federal agencies’  policies for requesting waivers (table 6).
section_title: Appendix III: Comments from the Department of Health and Human Services
section_title: Appendix IV: Contact and Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: In addition to the contact named above, Kim Yamane, Assistant Director;  Ellen W. Chu; Jill Hodges; Julian Klazkin; Linda Y.A. McIver; and Perry  Parsons made key contributions to this report.
section_title: Related GAO Products
paragraphs: Health Professional Shortage Areas: Problems Remain with Primary  Care Shortage Area Designation System. GAO-07-84. Washington, D.C.:  October 24, 2006.
Foreign Physicians: Preliminary Findings on the Use of J-1 Visa  Waivers to Practice in Underserved Areas. GAO-06-773T. Washington,  D.C.: May 18, 2006.
State Department: Stronger Action Needed to Improve Oversight and  Assess Risks of the Summer Work Travel and Trainee Categories of the  Exchange Visitor Program. GAO-06-106. Washington, D.C.: October 14,  2005.
Health Workforce: Ensuring Adequate Supply and Distribution Remains  Challenging. GAO-01-1042T. Washington, D.C.: August 1, 2001.
Health Care Access: Programs for Underserved Populations Could Be  Improved. GAO/T-HEHS-00-81. Washington, D.C.: March 23, 2000.
Foreign Physicians: Exchange Visitor Program Becoming Major Route  to Practicing in U.S. Underserved Areas. GAO/HEHS-97-26. Washington,  D.C.: December 30, 1996.
Health Care Shortage Areas: Designations Not a Useful Tool for  Directing Resources to the Underserved. GAO/HEHS-95-200. Washington,  D.C.: September 8, 1995.