J-1 visas allow foreign nationals to participate as exchange visitors in cultural and educational programs in the United States. USIA is responsible for managing the J-1 visa program and designates organizations as program sponsors. In 1995, over 9,000 foreign physicians with J-1 visas were in the United States for graduate medical education or training. These exchange visitors constituted about one-tenth of all individuals receiving graduate medical education (see app. II). Because many exchange visitors are in the United States for several years for graduate medical education and training, each year a few thousand new physicians receive J-1 visas and enter the United States to begin graduate medical education and training while a few thousand complete their training. To ensure that the J-1 visa program works as intended in passing learning and experience to other countries, the Congress has imposed restrictions on J-1 visa holders, including physicians in graduate medical education. These physicians are required to return to their home country (or to their country of last legal residence) for at least 2 years after completion of training. However, they may obtain a waiver of this requirement and remain in the United States. For most physicians, the waivers are requested on their behalf by a federal agency or by a state agency or department that is responsible for public health issues. These federal agencies and states generally request waivers of the 2-year foreign residence requirement so that the physicians can practice for several years in underserved areas (see table 1). The federal agencies and states submit these requests to USIA. USIA reviews the program, policy, and foreign relations aspects of the case and forwards its recommendations to the INS Commissioner. For waiver requests made by interested U.S. government agencies or states, INS may only grant the waiver if USIA submits a favorable recommendation. Figure 1 illustrates the waiver process. While HHS is the federal agency responsible for addressing physician shortages it does not use waivers to do so. HHS endorses the philosophy that exchange visitors return home after completing their training to make their new knowledge and skills available to their home countries. As a result, HHS does not support waivers for physicians to remain in the United States to practice in underserved areas. Instead, HHS administers other federal programs, such as NHSC, to address physician shortages in the United States. NHSC supplies physicians and other health professionals to underserved areas primarily by (1) awarding scholarships to students who agree to serve in a shortage area after their health professions training is complete and (2) repaying a set amount of educational loan debt for each year of service in a shortage area. On December 31, 1995, 848 NHSC physicians and 685 other NHSC professionals who received scholarships or federal loan repayment were practicing in underserved areas of the country. In addition to NHSC, HHS has other programs to address medical underservice. For example, HHS provides federal grant funding to community health centers that are required to accept all patients regardless of their ability to pay. Begun as an exceptions policy, the number of physicians receiving waivers of the 2-year foreign residence requirement for J-1 exchange visitors has grown more than tenfold in the past 5 years. Several factors have contributed to the increase: more hospitals and other facilities have found the waiver to be a means to fill their empty positions; more agencies and states are making requests; and physicians are actively seeking waivers, in some cases allegedly paying recruiters and immigration attorneys to find them a position. Waiver physicians are practicing in virtually every state; most are primary care physicians. The number of waivers being processed for physicians to practice in underserved areas each year has grown from 70 in 1990, to 1,374 in 1995 (see fig. 2). In 1995, the number of waivers being processed for physicians was greater than the number of NHSC physicians (1,267) practicing in underserved areas, and it was enough to offset about 27 percent of the total physician shortage identified by HHS. Indications are that in 1995, about half of the foreign physicians that were supposed to return home were granted waivers of this requirement to practice in an underserved area in the United States. Why do facilities want to employ foreign physicians through the use of the waivers? In responding to our survey and during our visits to health centers, physician offices, clinics, and other health care facilities where these physicians were practicing, many officials said that their facilities had turned to these physicians because they were unable to recruit U.S. physicians. For example, the administrator of a county public health unit in Florida commented that most U.S. physicians are not willing to work in rural areas, but she has found many physicians with J-1 visas who had excellent references and credentials and who were willing to practice there. She said it would be a “travesty” to health care in rural areas if these waiver physicians were not available. Other reasons cited for hiring these physicians are their superior foreign language skills and cultural familiarity with a facility’s patient population. For example, several physicians received waivers to practice at a migrant health center in Eastern Washington. These physicians were recruited, in part, because they are native Spanish speakers, which enables them to effectively treat the center’s Spanish-speaking patients. The sudden increase in the number of waivers being processed in 1994 and 1995 probably reflects the fact that facilities had additional places to turn to for requesting the waivers. By 1995, four U.S. government agencies and 23 states were requesting waivers of J-1 visa requirements for physicians. Before 1993, the only agency requesting waivers for a number of physicians to practice in underserved areas was ARC. ARC began requesting waivers in the 1980s for physicians to practice in Appalachia. However, ARC requested around 200 or fewer waivers per year, peaking at 266 waivers in 1993. In addition to ARC, since 1993 the Department of Transportation (DOT) has requested waivers for a handful of physicians to practice in one rural area where the U.S. Coast Guard operates. The rapid growth in waivers began in late 1993 and 1994, when the U.S. Departments of Agriculture (USDA) and Housing and Urban Development (HUD) began requesting them for physicians to serve their rural and urban constituents. Senior officials at both agencies said that they initially responded to a constituent request to support a specific physician; however, their offices were subsequently flooded with requests for waivers for other physicians. Agency officials said that they would like to limit the number of waivers processed by their agencies, but have not found a way of effectively restricting them. The number of waivers also increased because the authority for states to request waivers was passed in 1994, and 23 states requested waivers in calendar year 1995. As a result of the entry of these federal agencies and states, physicians seeking waivers were no longer limited to practice locations in Appalachia and areas serving DOT personnel; instead, they could practice in rural and urban areas across the country. However, HUD officials have recently decided to reassess the department’s waiver policy and stopped accepting requests after August 30, 1996, to conduct a review. Table 2 shows the number of waiver requests submitted to USIA by each agency in 1995 and the reason for the requests. For information on the number of waivers requested by each agency since 1990, see appendix V. Another factor in the increase in waivers may be the interest among physicians with J-1 visas themselves. Health care facility officials, as well as state and federal health officials, said that they have been inundated with inquiries from physicians who would like to obtain a waiver by working in a shortage area. In addition, officials at several facilities said that they were contacted by professional recruiters or immigration attorneys regarding the availability of a physician to meet their facility’s needs if the physician could obtain a waiver. Some facility officials and physicians reported paying up to $25,000 in immigration attorney or recruiter fees for assistance in matching a physician with a facility and processing the waiver. During our site visits to facilities where physicians who had received waivers were practicing, physicians cited several reasons why they wanted waivers, including that (1) they would not be able to apply the medical skills they had learned in the United States in their home countries, (2) they were concerned about violence in their home countries, (3) they wanted to serve in an underserved area, (4) their families and relatives were in the United States, and (5) they had a general desire to stay in the United States. In 1996, waiver physicians were practicing in 49 states and the District of Columbia—every state except Alaska. However, the degree to which they are relied on to relieve physician shortages varies greatly from state to state. To measure the extent of this reliance, we compared the number of waivers granted or in process in 1994 and 1995 with the number of physicians identified by HHS as needed to remove the shortage area designations in a state. In five states (Alabama, Kansas, Kentucky, North Dakota, and West Virginia), the number of physicians for whom waivers were processed equaled more than 75 percent of the number of physicians needed to remove these designations in the state. In other states, such as California, such physicians equal less than 10 percent of the identified need. Physicians with waivers are practicing in a variety of settings. Our survey results show that more than one-third of physicians who received their waivers through federal agencies are practicing in nonprofit community or migrant health centers and about one-fourth are in a private or group practice. The rest are practicing in hospitals, for-profit health centers, or other settings (see fig. 3). See appendix VI for more detailed information on the results of our survey of facilities. Using our survey results, we estimate that almost all physicians practicing on January 1, 1996, whose waivers were processed through federal agencies were practicing in primary care specialties. Overall, more than half of them were practicing in internal medicine (see fig. 4). The other major primary care specialties were pediatrics and family practice. We estimate that one-third of the waiver physicians who had primary care specialties also had subspecialties. The most prevalent subspecialty was nephrology (medicine concerned with kidney disease), which was reported for about 7 percent of the primary care physicians. Other subspecialties included infectious diseases, cardiology, and gastroenterology. Requesting facilities and state officials had mixed views on the usefulness of subspecialties for meeting their needs. Officials from some states said that physicians with subspecialties are not as desirable because they may not remain in the area to practice primary care. In fact, several states have policies to not request waivers for physicians who have subspecialties. On the other hand, officials at some facilities said that they recruited specific physicians, such as a nephrologist, because their subspecialties enabled them to meet the needs of their patient populations. Requests for waivers for physicians with J-1 visas are not coordinated effectively among the agencies and states or with other medical underservice programs, such as NHSC. No single entity is responsible for coordinating practice locations of waiver physicians and HHS, perhaps the most logical candidate for doing so, opposes the way in which the waivers are being used. Because no single entity is responsible for coordinating physicians’ practice locations, the requesting agencies set up varying policies for requesting the waivers. Because of the lack of coordination, the number of waivers processed for physicians to practice in some states has been more than the amount needed to alleviate the identified physician shortage in that state. No single agency has management responsibility for use of the waivers to address physician shortages. While USIA and INS must recommend and approve all waivers of the 2-year foreign residence requirement for physicians requested by interested government agencies and states, USIA and INS officials said that they recommend and approve virtually all waiver requests. USIA officials said that while they check for required documentation, they almost always rely on the interested government agencies’ assertions that the waivers are in the public interest. INS officials said that refusal of the waiver is extremely rare if USIA has given a favorable recommendation. INS officials said that they are not in a position to second-guess USIA or the interested government agency as to whether the public interest would be served if the waiver was granted. “when the application demonstrates that the exchange visitor is needed merely to provide services for a limited geographical area and/or to alleviate a local community or institutional manpower shortage, however serious.” “In summary, this Department has viewed the J-1 visa to be a means of sharing advanced medical knowledge and allowing the benefits of training to accrue to the home country. The Department does not view waivers as a mechanism to help resolve the problems of shortage areas.” Without any overall management of the use of waivers, waiver policies vary considerably between agencies, leading in some cases to “shopping” by the physicians seeking a waiver to obtain the most advantageous terms. Policies vary with regard to such matters as eligible practice locations and state involvement and the consequences of the physician’s failure to complete the agreed-upon length of service. For example, ARC restricts physicians to practice locations in federally designated Health Professional Shortage Areas, while the physicians who received waivers through USDA and HUD have been allowed to practice in other areas, including designated Medically Underserved Areas. ARC officials said that they excluded the Medically Underserved Area designations because (1) this designation is not an accurate measure of physician shortage; (2) the designations have not been updated; and (3) including them would allow physicians to practice in virtually any location in Appalachia.Federal agency and state officials also said that and our review found cases where physicians or their immigration attorneys were shopping between agencies; that is, requesting waivers through multiple agencies at the same time. State health officials commented that they would like consistency in waiver policies across federal agencies. One state health official commented that participation of multiple federal agencies has resulted in confusing and sometimes contradictory program guidelines and has placed a burden on states to coordinate programs. Thus far, the various efforts to use waiver physicians to address medical underservice have operated largely independent of each other and of other programs to address medical underservice. By 1995, there were nearly 30 federal agencies and states processing requests for waivers for physicians with J-1 visas. Most of them were operating independent of one another. The four federal agencies have no formal process for coordinating their waiver requests and they have overlapping jurisdictions. For example, while USDA’s policy has been to request waivers for rural areas and HUD’s policy has been to request waivers for urban areas, the two agencies have not agreed on which areas are rural and which are urban. As a result, we found some locations, such as Buffalo, New York, and Decatur, Illinois, where USDA requested waivers for one or more physicians and HUD requested waivers for additional physicians to practice in the same city and in some cases the same facility. There is no mechanism for each federal agency to know how many waivers the other has requested to address the physician shortage in an area. Coordination is also lacking between state and federal efforts. State health officials do not always know where physicians receiving waivers through federal agencies are practicing and, therefore, they cannot coordinate these placements with state programs to address medical underservice. While ARC requires that facilities’ requests for waivers come through the states, other agencies do not. This leads to situations where the states are unaware of the level of placements that are occurring. For example, health department officials in Texas, which does not request waivers for physicians under the state authority, did not know how many physicians received waivers through federal agencies to practice in the state. As a result, when we scheduled our visits to practice sites in Texas, state officials were surprised to find out that federal agency records showed over 20 waiver physicians practicing in El Paso. Waivers for physicians also are not well-coordinated with other programs addressing underservice, such as those operated by HHS. One such program is NHSC. When combined with NHSC physicians, federal agencies and states have requested waivers for more physicians than are needed to remove the shortage designations in some states. We found that for eight states, the number of physicians who received waivers in 1994 and 1995 (or had waivers in process), combined with the number of NHSC physicians in service at the end of 1995, exceeded the number of physicians needed to remove the shortage area designations in the state. (See app. VII for more information on the identified need, number of waivers being processed, and the number of NHSC physicians practicing in each state.) Without information on the number of physicians needed in the area and the number of NHSC and waiver physicians already addressing that need, federal agencies and states will not know if the needs of an area are already being met when considering whether or not to request a waiver for a physician. Another HHS program with which physician waivers are not well-coordinated is the Community Health Center program. This means that federal agencies and states may not know of problems identified by HHS when considering requests from community health centers. For example, waivers were requested through HUD for several physicians to practice at a health center that had its HHS funding discontinued due to financial management problems. When requesting the waivers for these physicians, HUD officials did not know that HHS had identified problems with the health center. As a result, they could not take those problems into consideration when deciding whether the waivers were in HUD’s and the public’s interest. Coordination between the agencies involved in the requests and other programs to address medical underservice is important, because not all the agencies processing the waiver requests have expertise in addressing health care issues. For example, USDA and HUD officials involved in the waiver requests said that their offices lacked expertise in health issues. In USDA, waivers for physicians are processed in the department’s Agricultural Research Service by an office that has experience processing waiver requests for a small number of research scientists who were in the United States as exchange visitors. At HUD, the waivers were processed in the Office of the Deputy Assistant Secretary for Intergovernmental Relations. Although most physicians who obtain waivers of their J-1 visa foreign residence requirement are apparently complying with the terms of their service agreements, weak controls mean there is little to deter physicians or their employers from failing to comply if they choose to break these terms. For example, we found instances in which a physician never practiced at the intended facility, unbeknownst to the agency processing the request. Including all current waiver physicians when assessing compliance with requesting agency policies can present somewhat of a misleading picture, because so many of these physicians have been at their jobs for a relatively short time, in many cases for less than 1 year. To provide a more accurate picture of whether physicians stay for the full term of their agreement, we analyzed those physicians whose waivers had been requested through ARC from 1990 to 1992. We estimate that 90 percent completed the minimum employment period required by ARC, which was 2-years, for the facility that requested the waiver. On January 1, 1996, over one-fourth (28 percent) were still practicing at the same facility that requested the waiver and nearly half of these (13 percent) had been there for more than 4 years. We also examined the shorter-term compliance record of all physicians practicing on January 1, 1996, after receiving waivers through federal agencies between 1994 and 1995. We estimate that 96 percent of them were working at the facility for which the waiver was requested. The remaining 4 percent had left or did not plan to work at that facility. Although this percentage is similar to the percentage of ARC physicians who did not complete their 2-year agreements, the percentage may grow because many of the physicians had completed only a fraction of their employment contract by the start of 1996. For example, none of the physicians with waivers through HUD had been practicing for more than 1 year by that date. For the physicians in our sample and in the states we visited, several reasons they were not practicing at the location for which the waiver was requested had to do with changes made by the facility that initiated the request. We found cases in which a facility made the request and then determined that the physician was no longer needed. In at least one case, it appears that the employer made this determination before the waiver was even granted, but the physician still received the waiver. Here are examples in which the facility changed its mind: In letters asking USDA to request waivers for three physicians, a clinic in Illinois said that the physicians were needed to help meet an urgent primary care delivery crises in the rural community where the practice site was located. Six months after one of the physicians began working there, she was terminated because the clinic had determined that it was overstaffed. She is now practicing in another city in Illinois that has an identified shortage of physicians who serve Medicaid patients. The second physician was transferred from the location on the waiver request to another location that is not in a federally designated shortage area. The third physician was practicing only part-time at the practice site for which the waiver was requested. He said that because there were not enough patients in that location, he spends about half his time working at the main clinic in Champaign, Illinois. A medical group asked HUD to request waivers for three physicians to work at a practice purchased from a retiring physician outside of Atlanta. When we called the practice site, we were told that only one of the three was practicing there. An official from the medical group said that the practice no longer had enough patients to support these physicians. As a result, one physician never worked at the site, one physician worked a brief period and then went to practice at a prison in Michigan, and one physician remained to work for the new employer after the practice was sold. INS officials said that waivers had been approved for all three physicians, including the one who was never employed there. Before we notified them, HUD officials were unaware that the facility had been sold and that two of the physicians were not practicing there. We also found instances in which the reason for not meeting the requirements of an agreement resulted from the physician’s actions. For example, in two separate cases, physicians were fired when they refused to complete the requirement for working 40 hours a week at the requesting facility. In one instance, the fired physician notified USDA that he was going to practice at another hospital and when USDA officials told him he could not because the hospital was not in a shortage area, the physician broke off contact with them. The facility official said that he had heard that the physician was pursuing additional graduate medical education in the United States. In the second instance, the facility reported the physician’s firing directly to INS, which revoked his nonimmigrant work status. Reviews conducted by ARC’s Inspector General have disclosed similar instances in which conditions of agreements were not met. Six of eight reviews conducted by the Inspector General from 1994 to 1995 found that contrary to ARC policy, some physicians were not practicing primary care at least 40 hours per week in a Health Professional Shortage Area. Instead, employers were using the physicians in subspecialty practices or in locations not designated as shortage areas. Agency controls to help ensure that physicians comply with waiver agreements vary among the federal agencies and states. These controls range from periodic reports and site visits, to reliance on employers to enforce the employment contracts. For example, ARC requires the facilities to verify and the waiver physicians to certify that they are complying with ARC policies. In addition, the ARC Inspector General conducts site visits to the physicians’ practice locations. In contrast, while HUD and USDA officials said that they had started or planned to start requiring periodic reports, officials at both agencies said that they do not have the staff resources to monitor physician compliance. These officials said that because the use of waivers to address physician shortages is not authorized or funded as a program, their agencies do not have the resources available to effectively manage it as a program. In its site visits to monitor compliance, ARC’s Inspector General attributed most of the problems identified to the employers. However, for waivers requested through both federal agencies and states, the applicable federal laws and regulations do not specify penalties against employers that fail to comply with agency policies. ARC tries to address this shortcoming by requiring employers to sign a statement certifying that they will comply with the waiver policy, and applications from employers found to be in violation of the policy receive additional scrutiny to ensure that the problems have been corrected. The growth in the number of waiver physicians has not gone unnoticed by federal agency officials and legislators. They have recently taken actions that could address some of the coordination and compliance problems identified. A group of federal agency officials has met informally to discuss waiver requests and USIA has proposed regulations to make the waiver requests more consistent. In addition, recent amendments to the Immigration and Nationality Act impose additional requirements for waivers obtained through federal agencies. The new regulations, if finalized, and the 1996 amendments could address many of the coordination and compliance problems, but not all of them. Recognizing the need for better coordination, officials from USIA, INS, HHS, and the requesting federal agencies have been meeting since late 1995 to discuss the use of waivers to address physician shortages. The officials formed an informal interagency group that has discussed revising regulations addressing waiver requests. USIA, in working with the other agencies, published a proposed regulation in the Federal Register on September 5, 1996. In the preamble to the proposed regulation, USIA noted that with the entry of USDA and HUD into the waiver process, inconsistency in the administration of waiver requests among the different agencies has created some confusion. For a request by a U.S. government agency, the regulation would condition approval on the physician’s commitment to practice primary care for at least 3 years in a designated Health Professional Shortage Area or a Medically Underserved Area or to practice psychiatric care in a mental health Health Professional Shortage Area. To prevent physicians from shopping between agencies, the foreign medical graduate would have to certify that he or she is only requesting a waiver through one agency. The Omnibus Consolidated Appropriations Act, 1997, included amendments to the Immigration and Nationality Act that create greater consistency among waiver efforts by subjecting state and federally sponsored waiver physicians to the same statutory requirements. The amendments strengthen penalty provisions for federally sponsored waiver physicians by prohibiting them from obtaining permanent residence or U.S. citizenship without completing the required 3-year agreement. If they fail to complete the 3-year agreement, they must fulfill the 2-year foreign residence requirement. These changes (1) make the waiver conditions much more consistent, which may help to alleviate the confusion cited by agency officials, and (2) help to strengthen controls with regard to penalties for waivers requested through federal agencies. While the efforts of the interagency group and enactment of the 1996 amendments should improve coordination of the waiver requests for physicians with J-1 visas, they will leave several problems unaddressed. Specifically, they do not address the following issues: Fully coordinating with other underservice programs or with waiver requests by other agencies. The amendments neither designate an agency as responsible for managing the waivers nor require the waivers to be coordinated with HHS programs such as NHSC or the Community Health Center program. Among federal agencies and states requesting the waivers, the problems of overlapping jurisdictions and the lack of information on the practice locations of waiver physicians could result in more physicians practicing in an area than are needed, as identified by HHS; a continued need for physicians in other areas; and a lack of coordination with state efforts to address physicians shortages. In addition, although HHS has started to collect information on the number of physicians practicing under waivers in an area, there is no directive for this information to be used or shared in making decisions on waivers for physicians or other federal assistance. Ensuring that the use of waivers for physicians is a last resort. In an effort to ensure that the employers have a true need for a physician, ARC, USDA, and HUD policies, as well as the proposed USIA regulations, require the facilities to provide some documentation of past recruitment efforts. This procedure, however, does not ensure that the use of waivers for physicians is the option of last resort for areas with physician shortages. In some cases it appears that other qualified physicians are available, but the facility prefers to hire the physicians with J-1 visas. For example, officials from one multispecialty clinic told us that they interviewed several applicants for a specialist physician position, including candidates who were not under J-1 visas, but they chose the physician with a J-1 visa and obtained a waiver because he was the most qualified. The use of waivers is now a ready means for acquiring physicians, some of whom are being actively marketed by the physicians themselves or placement specialists such as recruiters. The current statute and regulations do not require waivers to be used only as a last resort. Monitoring compliance. It is unclear whether agencies would devote sufficient resources to effectively monitor compliance. USDA, for example, relies on employers to enforce the employment contracts, citing a lack of staff resources to conduct its own monitoring. However, as we and ARC’s Inspector General found, many of the examples of physicians who failed to comply with agency policies resulted from actions taken by the employers. As a result, a reliance on employers to do the policing does not appear adequate to prevent the kinds of situations we found. HUD officials also said that their monitoring efforts were limited by the availability of staff resources. Addressing the needs of the medically underserved. Under existing procedures, locating a waiver physician in a medical shortage area is no guarantee that the needs of the underserved will be addressed. An area’s underserved may be only a specific part of the population (such as migrant workers or low-income people), and not all federal agencies’ and states’ policies contain requirements or monitoring to ensure that a physician’s practice includes such groups. For example, if the underserved part of the population is low-income, the requesting agencies’ and states’ policies do not all require that a waiver physician in such an area accept Medicaid, have a sliding fee scale, or accept anyone for services regardless of his or her ability to pay. In one area where the identified need was care for migrant farm workers, a waiver physician was in a group practice a block away from a federally funded migrant health center. A senior official at the migrant health center said that the waiver physician did not impact the center’s patient load because they both served different patient populations. Establishing penalties against a facility for failing to comply with agency policies. The new regulations and the 1996 amendments do not establish any penalties for employers who fail to comply. The ARC Inspector General noted that the most significant programmatic issue that surfaced during that office’s review was the limited accountability of employers and the lack of potential actions against employers who did not use physicians with waivers in accordance with the intended purposes noted in the program. The use of waivers for physicians with J-1 visa requirements has become so extensive that this exception policy now resembles a full-fledged program for addressing medical underservice in the United States. Many health care facilities and states cite examples of the utility of these waivers in providing a qualified physician for an underserved area. However, while the agencies involved in processing the waivers are operating with the best of intentions, the growing use of waivers is not being managed as a program, and this is having detrimental results. Federal efforts to address physician shortages are not coordinated among the federal agencies or with the states. Several agencies, including those not traditionally involved in physician supply issues, have set up de facto physician supply programs using their existing authority and agency resources. Despite some improvements, monitoring efforts to ensure that physicians fulfill the terms of their agreements remain spotty. Accountability for reducing the actual conditions of underservice is limited. Physicians can practice in underserved areas but not actually target their efforts to that part of the population that is underserved. The rapid growth in waivers for physicians makes this an opportune time for the Congress to reassess what it wants the waiver provision to accomplish. The running disagreement between HHS and other federal agencies about the role of waivers in addressing physician shortages in underserved areas needs resolution, and better coordination and management of the overall effort are needed if it is to be continued. If the Congress wants to continue to address medical underservice in the United States through the use of waivers for physicians with J-1 visa requirements, it should consider requiring that the use of such waivers be managed as a program. Specifically, the Congress should consider the following: Clarifying how the use of waivers for these physicians fits into the overall federal strategy to address medical underservice. This should include determining the size of the waiver program and establishing how it should be coordinated with other federal programs. Designating leadership responsibility for managing the program. This responsibility could be given to a single federal agency, such as HHS; to several federal agencies, for example, through a memorandum of understanding; or it could be delegated to the states. Establishing penalties against facilities that fail to comply with requirements of the waiver. Directing the entity(ies) managing the program to implement procedures and criteria for the selection and placement of physicians and for monitoring compliance with waiver requirements. These procedures and criteria could include requiring the state to clearly support the use of the physician for addressing unmet need and to show that it has sought other options for fulfilling this need. We provided a draft copy of this report to seven agencies that are involved with waivers for physicians to practice in underserved areas. ARC, USDA, and USIA provided formal written comments (see apps. VIII, IX, and X). These comments indicate general agreement with our conclusions and matters for congressional consideration. HUD and Justice (the parent department for INS) chose not to provide formal comments. However, we discussed our findings with HUD and INS officials, and they raised no objections to our findings or matters for congressional consideration. DOT has had limited involvement in waivers for physicians with J-1 visas and did not have comments on the draft report. HHS did not submit formal comments by the end of our 30-day comment period. However, the Director of the department’s Office of International Affairs (who also chairs the department’s Exchange Visitor Waiver Review Board) informed us that his office had fully reviewed the draft report and was in general agreement with the findings. Regarding our matters for congressional consideration, he said that HHS favored the option of delegating responsibility for the waivers to the states. The three agencies that provided formal written comments also expressed their support for the need for better coordination between the participating agencies, states, and other programs to address medical underservice. One agency, USDA, also expressed concern about the lack of available funding to operate its program effectively. USDA suggested that an alternative to funding the program from appropriated research funds would be to initiate a fee-for-service type application fee to offset operational costs, which would require legislation to authorize the collection and utilizations of fees. We concur that any entity involved in managing waiver requests for physicians should commit adequate resources for oversight and operational support to ensure that the physicians address unmet needs for physician resources. Although we did not examine financing options for managing the waivers in our review, we did note that a few states, such as Michigan, have been requiring user fees of up to $500 per application. We also received comments on technical matters from several of the agencies, which we considered in preparing our final report. We are sending copies of this report to the Secretaries of Agriculture, Health and Human Services, Housing and Urban Development, and Transportation, as well as the Director of the United States Information Agency, the Federal Co-Chairman of the Appalachian Regional Commission, and the Attorney General. We also will make copies available to others on request. Please contact me on (202) 512-7119 if you or your staff have any questions. Major contributors to this report are listed in appendix XI. To accomplish our objectives, we interviewed (1) federal agency officials responsible for requesting the waivers at ARC, HUD, USDA, and DOT; (2) HHS officials in the department’s Office of International Affairs and the Health Resources and Services Administration; (3) officials responsible for processing the waiver requests at USIA and INS, including INS service centers; (4) officials from the Department of Labor and the State Department; and (5) officials from the Educational Commission for Foreign Medical Graduates (ECFMG), the National Association of Community Health Centers, the American Medical Association (AMA), the Council on Graduate Medical Education (COGME), and the U.S. Commission on Immigration Reform. We also reviewed relevant legislation, studies, and policy documents and conducted two mail surveys: one of the states regarding the use of waivers of the J-1 visa foreign residence requirement for physicians in their states, and another of the facilities that requested such waivers for physicians. We obtained and analyzed data on requests for waivers for physicians from USIA and the requesting federal agencies and reviewed a small sample of case files. We also visited three states—Washington, Texas, and Georgia. We selected these three states for a cross-section of states where waiver physicians were practicing: Washington was quick to establish a state program; Texas had a large number of physicians with waivers through federal agencies but the state was not requesting waivers; and Georgia had a state program as well as physicians whose waivers were requested through ARC, HUD, and USDA. During our site visits, we met with state and other health officials, visited 14 sites where waiver physicians were practicing, and interviewed health care facility officials and 20 physicians who received waivers. We selected the sites in order to visit physicians in a variety of practice settings, including federally funded community and migrant health centers, a health center serving residents in public housing, city and county health departments, a capitated-rate program for the Medicare- and Medicaid-eligible elderly, and private and group practices affiliated with both public and for-profit hospitals. We conducted our work between November 1995 and September 1996 in accordance with generally accepted government auditing standards. To determine the number of waivers for physicians granted at the request of ARC, USDA, and HUD, we requested copies of the agencies’ databases. Each database contained information about when the agency requested that USIA recommend the waiver. We used the date that the agencies sent the request to USIA in our calculations because neither USIA nor INS has a cost-effective means of identifying waiver requests by occupation and USIA and INS officials said that they recommended or approved virtually all the physician waiver requests made by the interested U.S. government agencies. While we did not review the agencies’ computer-based systems, we did review the requesting agencies’ data for consistency and accuracy and selectively compared the agency data with that held by USIA. We obtained information on the waiver requests made by DOT from its Office of the General Counsel. We obtained information on state requests for waivers from our survey of states regarding waivers for physicians and follow-up telephone calls to state officials. Our scope did not include waiver requests from VA or requests from other agencies for physicians to conduct research. Because the agencies requesting waivers do not consistently track the practice dates of the physicians, we could not identify the number of physicians in practice at any given point in time. Instead, we used the dates that the agencies and states submitted their requests for waivers to USIA and assumed that those physicians whose waivers were requested in 1994 or 1995 were either already practicing at the facility listed in agency data on December 31, 1995, or had their waivers in process to begin practicing shortly thereafter. We compared this number with (1) the number of physicians needed to remove the primary care Health Professional Shortage Area designations in the state on December 31, 1995, and (2) the number of NHSC physicians (who received NHSC scholarships or NHSC federal loan repayment in return for practicing in an underserved area) who were practicing on December 31, 1995. We obtained these data from HHS’ Health Resources and Services Administration. We also compared the number of waivers with the number of NHSC physicians practicing in underserved areas on September 30, 1995, including NHSC physicians who did not have NHSC scholarship or federal loan repayment obligations. To estimate the number of physicians who completed graduate medical education and training in 1995 who would be subject to the 2-year foreign residence requirement, we subtracted the number of exchange visitor physicians who were continuing applicants in the 1995-96 academic year from the number of physicians sponsored by ECFMG in the prior academic year. While this number is not exact because it may include a small number of physicians who were involved in research and some physicians who did not complete their training, it does represent a reasonable estimate of the number of exchange visitor physicians with J-1 visas who completed graduate medical education or training who would be required to return home without a waiver to remain in the United States. The number of waiver requests for physicians to practice in underserved areas that the agencies sent to USIA in 1995 (1,374) is about 64 percent of this figure. Therefore, we estimate that half of the physicians who were supposed to return home after completing their graduate medical education or training received waivers to practice in underserved areas in the United States instead. To identify characteristics of the physicians who received waivers of the J-1 visa foreign residence requirement and to measure the compliance and retention of these physicians, we selected a random sample of 40 from 355 physicians for whom ARC requested waivers between 1990 and 1992. Because most federal agencies only began requesting waivers in the past several years, we also selected a random sample of 211 of 1,994 physicians for whom ARC, DOT, HUD, and USDA received waiver requests in 1994 and 1995 (this was a stratified sample, including 40 of 362 ARC requests; 2 of 2 DOT requests; 49 of 477 HUD requests, and 120 of 1,153 USDA requests). We sent a questionnaire to the contact person at the facility that had requested the waivers, using the information provided by the federal agencies. For each physician, we asked the contact person to tell us (1) if the physician worked or planned to work at the facility; (2) if the physician was working at the facility as of January 1, 1996; (3) if the physician left and the date he or she stopped working at the facility; (4) whether or not the physician obtained permanent residency during his or her employment; and (5) the physician’s medical specialty, subspecialty, and practice setting. We received responses for 39 of the 40 physicians in our 1990 to 1992 ARC sample and for 200 of 211 physicians in our 1994 to 1995 samples (38 of 40 ARC physicians, 2 of 2 DOT physicians, 49 of 49 HUD physicians, and 111 of 120 USDA physicians). We used the survey results of the 1990 to 1992 ARC sample to estimate the rate of completion of ARC’s required 2-year contract among all waiver physicians whose waivers were requested between 1990 and 1992. We counted those physicians who worked for at least 1.75 years as meeting the ARC minimum contract period at that time, which was 2 years. We used 1.75 years of practice as our measure of compliance to allow for vacation and other leave. At a 95-percent confidence level, the rate of compliance among the 1990 to 1992 requests is at least 80 percent and the percent still at the requesting facility on January 1, 1996, is at least 19 percent. We used the survey results of the 1994 to 1995 samples to estimate the rate of compliance, to date, of physicians whose waiver requests were received by ARC, DOT, HUD, and USDA from 1994 to 1995. We counted those physicians who were working on January 1, 1996, for the facility listed in agency data as in compliance. At a 95-percent confidence level, the rate of compliance among the 1994 to 1995 requests (those practicing on January 1) is at least 93 percent. We also used the survey results of the 1994 to 1995 samples to estimate the practice specialties and practice settings of physicians who were practicing on January 1, 1996. For this analysis, we included those 150 physicians who were practicing on January 1, 1996, for the facilities listed by the agency. The estimates at the 95-percent confidence intervals are shown in tables VI.2 and VI.3. We also obtained comments on the use of waivers for physicians from the survey respondents. To identify the states’ participation in requesting waivers for physicians, we used a questionnaire for information on (1) whether or not the state had requested or planned to request waivers for physicians with J-1 visas in fiscal years 1995 and 1996, and (2) the state’s involvement in waivers for these physicians. We sent a questionnaire to the contact person provided by USIA or the official responsible for public health issues in all 54 eligible jurisdictions, including the 50 states, the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands. Each state reported on the number of waivers requested by the state, if any; factors considered in state requests; monitoring activities; and state involvement in requests for waivers made by federal agencies. The respondents also commented on the use of waivers for physicians to address medical underservice and provided a copy of their state’s written policies, if any, regarding these waivers. In addition, to obtain information on the number of waivers for physicians requested by the states in 1995, we telephoned officials at those states that indicated they had requested waivers in fiscal years 1995 or 1996. To determine the conditions attached to the waivers, we interviewed state and federal agency officials, reviewed their written waiver policies, and analyzed the results of our state survey. To look at coordination of physician placements, we cross-tabulated the agency data on waiver requests received by the agencies between 1994 and 1995 by state and selected those physicians whose waiver requests were sent to USIA between 1994 and 1995. We obtained the number of physicians who were NHSC scholarship or federal loan repayment recipients who were practicing in each state as of December 31, 1995, from HHS’ Bureau of Primary Health Care. We added the number of waiver physicians and NHSC physicians and compared them with the number of full-time-equivalent physicians needed to remove primary care Health Professional Shortage Area designations in that state as of December 31, 1995. We used the shortage area dedesignation level because it is the primary measurement used by HHS and the requesting agencies to establish the need for physicians. We used USIA’s data file to identify those locations for which more than one agency requested waivers for physicians and checked the requesting agencies’ data to see if they showed a request for that practice location. We identified instances where physicians did not comply with the terms of the waiver through (1) discussions with the ARC Inspector General and a review of reports from that office, (2) our survey of facilities where requesting agencies believed that the physicians were practicing, (3) site visits to facilities where the physicians were supposed to be practicing, and (4) discussions with USIA and other agency officials. If a facility indicated that the physician never worked there, we contacted the facility, INS, or both to obtain information on the reason the physician never worked there and to confirm that a waiver had been granted. We also reviewed case files at the requesting agencies and USIA to check for documentation, if any, of the physician’s departure from the facility or noncompliance. For physicians that did not work at or left the facilities, we tried to locate the physician through AMA data; the unique provider identification number database, which is maintained by the Medicare program; telephone listings; state licensing boards; and other sources. Exchange visitors are only a portion of physicians in graduate medical education programs. As shown in table II.1, about 1 in 10 physicians in programs accredited by ACGME was an exchange visitor in August 1995. Of those who were international medical graduates—physicians who did not graduate from U.S. or Canadian medical schools—about 1 in 3 was an exchange visitor. Only these exchange visitor physicians are subject to the J-visa 2-year foreign residence requirement. Hence, while policy changes regarding waivers for exchange visitors will affect more than one-third of the international medical graduates in graduate medical education or training, most international medical graduates will not be affected. Exchange visitor (J-visa) Nonimmigrant (H-visa) Does not include graduates of Canadian medical schools. Medical school type was not indicated for 454 residents (0.5 percent of all residents). Under the Mutual Educational and Cultural Exchange Act of 1961, the Director of USIA establishes programs intended to promote mutual understanding between the people of the United States and other countries by means of educational and cultural exchanges. Under these exchange visitor (J-1 visa) programs, designated organizations sponsor nonimmigrant aliens’ temporary visits to the United States for the purposes of teaching, instructing or lecturing, studying, observing, conducting research, consulting, demonstrating special skills, or receiving training. ECFMG is the designated sponsor for exchange visitors participating in graduate medical education. After completing this program, it is expected that participants will return to their home countries and impart what they have learned and experienced to the people of their country. Section 212(e) of the Immigration and Nationality Act requires that certain J-1 visa program participants, including participants in graduate medical education, reside at least 2 years in the countries of their nationalities or last residences after leaving the United States. They must meet this requirement before they are eligible to apply for nonimmigrant visas (H and L) as temporary workers, for permanent residencies in the United States, or as immigrants. There was no 2-year foreign residence requirement or waiver provision in the exchange visitor program authorized with the passage of the U.S. Information and Educational Exchange Act of 1948. The act required participants to depart the United States after completing their programs. The 2-year foreign residence requirement and its related waiver provision evolved through a number of legislative changes after the exchange visitor program was authorized in 1948. “the amendment would make perfectly clear to all concerned...and, above all, the foreign nationals themselves—that the exchange program is not an immigration program and should not be used to circumvent the operation of the immigration laws.” The 1956 amendment also provided for a waiver of the foreign residence requirement on the basis of a request from an interested U.S. government agency showing the waiver to be in the public interest. “To make available the services of exchangees who possess talents desired by our universities, foundations and other institutions, the language of the House bill was modified to permit the waiver of the foreign residence requirement on the request of an interested U.S. Government agency.” An amendment to the foreign residence provision in 1970 removed the blanket application of the foreign residence requirement for exchange visitors and imposed it only on participants (1) whose participation was financed in some way by the United States or their home countries or (2) whose home countries clearly needed their services. Also, participants could no longer meet the 2-year foreign residence requirement by residing in other foreign countries but had to reside in the countries of their nationalities or their last foreign residences before coming to the United States. This requirement still applies. The 1970 act also established two additional bases for waivers: persecution because of race, religion, or political opinion and statements by the participant’s home countries that they had no objections to the waivers. These bases still apply except that the statement of no-objection waiver is no longer available to participants in graduate medical education or training. “that there is no longer an insufficient number of physicians and surgeons in the United States such that there is no further need for affording preference to alien physicians in admission to the United States under the Immigration and Nationality Act.” In light of this finding, the Congress tightened immigration laws for foreign doctors and strengthened requirements affecting J-1 visa program participants who were coming to the United States for graduate medical education or training. The latter were made subject to the 2-year foreign residence requirement whether or not their programs were financed by a government, made ineligible to apply for waivers on the basis of no-objection statements from their home countries, limited to 3-year stays in the United States, required to make a commitment to return to their home countries after completing their training, and required to provide written assurance by their home countries that after completing their training and returning home, they would be appointed to positions in which they would fully use the skills acquired in their education or training. In 1981, USIA asked the Congress to extend the limit up to 7 years for medical doctors to encourage them to study in the United States rather than in a Communist country. The House Committee on the Judiciary questioned USIA officials regarding the likelihood that physicians would be willing to return home after 7 years, during which time they may have raised families in the United States. The Congress increased the usual permissible duration of stay to 7 years, but it imposed additional requirements: Graduate medical education or training participants were required, as a continuing reminder, to furnish annual affidavits to INS attesting that they would return to their home countries upon completion of the education or training for which they came to the United States. U.S. officials were required to issue an annual report to the Congress on participants who had submitted affidavits, including their names and addresses, the programs in which they are participating, and their status in the programs. In reporting on this legislation, the House Committee on the Judiciary “notes the flagrant abuse of the exchange program during the past decade and seeks to alleviate possible ‘brain drain’ from various countries.” It said that the affidavits were to ensure that the physicians comply with the terms of their agreement. Amendment of the Immigration and Nationality Act in 1994 established another basis for physicians to obtain waivers of the J-1 visa foreign residence requirement. Under the amendment, up to 20 waivers for physicians with J-1 visas may be granted at the request of a statedepartment of public health or its equivalent each fiscal year. The law imposed several conditions for state-requested waivers: The alien physician must (1) demonstrate a bona fide offer of full-time employment at a health facility, (2) agree to begin employment at that facility within 90 days of receiving the waiver, and (3) agree to work there for at least 3 years while maintaining a nonimmigrant work status (H-1B visa). (The physician’s status as a nonimmigrant may not be changed until the employment contract is fulfilled.) The alien physician must agree to practice medicine for at least 3 years in a geographic area or areas designated by the Secretary of HHS as having a shortage of health care professionals. If the alien physician is otherwise contractually obligated to return to a foreign country, that country’s government must furnish a statement to the Director of USIA that it has no objection to a waiver. If the physician fails to fulfill the contract, he or she must reside and be physically present in the country of his or her nationality or last residence for at least 2 years after departing the United States before becoming eligible to apply for an immigrant visa, for permanent residence, or for any other change of nonimmigrant status The 1994 amendments apply only to exchange visitors who were admitted to the United States under a J-visa or acquired J-visa status before June 1, 1996. Other amendments to the Immigration and Nationality Act regarding waivers for physicians with J-1 visas were passed in the 104th Congress. The amendments were included in the Omnibus Consolidated Appropriations Act, 1997, and (1) impose additional requirements for waivers requested by interested U.S. government agencies, and (2) extend authorization for waivers for aliens entering the United States with a J-visa or acquiring such status through May 31, 2002. The amendments subject physicians seeking waivers through interested U.S. government agencies to some of the same requirements as those sponsored by state agencies. For example, the amendments require such physicians to (1) agree to work for at least 3 years for the health facility named in the application, (2) work in an area designated by the Secretary of HHS as having a shortage of health care professionals, (3) begin work within 90 days of receipt of the waiver, and (4) maintain a nonimmigrant status until their 3-year commitment is completed. Physicians who do not fulfill this commitment become subject to the 2-year foreign residence requirement. The U.S. General Accounting Office is conducting a review of J-1 visa waivers for physicians to practice in medically underserved communities. As part of this study, we are collecting information on state J-1 visa waiver programs as well as on states’ roles in requests for J-1 visa waivers made by U.S. government agencies. We are sending this questionnaire to all 50 states, the District of Columbia, Guam, Puerto Rico, and the Virgin Islands of the United States. Please complete the questionnaire and return it, along with a copy of your state’s policies on J-1 visa waivers for physicians, if any, within ONE WEEK of receipt. You can use the enclosed pre-addressed envelope or send it via FAX on (206) 287-4872. The questionnaire should take about 15 minutes to complete. Please provide the name, title, and telephone number of the individual who completed this questionnaire so that we may consult him or her, if necessary, for clarification of your responses or additional information. J-1 visa waivers did your state receive from employers between October 1, 1995 and March 31, 1996? (enter 0 if no applications were received during that time) 112 (total) applications please continue on next page--> ) 5. Based on your current situation, how 7. We are also interested in any activities your adequate is the annual limit of 20 state J-1 visa waivers to meet your state’s needs for physicians under this program? (check one) state conducts to monitor compliance with the conditions of the J-1 visa waiver. Which of the following activities, if any, does your state conduct or intend to conduct this year for state J-1 visa waiver physicians? (check all that apply) 18% much more than adequate 29% more than adequate 27% adequate 35% We require periodic reports by the 6% less than adequate 0% much less than adequate 50% We require periodic reports by the 18% too early to tell 21% We conduct periodic site visits 82% We rely on the employers to enforce 6. Listed below are some of the factors you might consider when reviewing state J-1 visa waiver applications. Which of the following factors, if any, does your state consider in deciding whether to request state J-1 visa waivers? (check all that apply) 15% We rely on other federal or state 38% We act in response to reports from other federal or state agencies 32% other (please specify) 97% Whether the practice location is in a health professional shortage area (HPSA) please continue on next page--> 65% Whether the practice location is in a medically underserved area/population (MUA/MUP) 29% Whether other state J-1 visa waiver physicians are practicing in the area 24% Whether other J-1 visa waiver physicians who received waivers through U.S. government agencies are practicing in the area 27% Whether physicians under National Health Service Corps (NHSC) obligations are practicing in the area 85% Whether the facility has tried recruiting in the past without success 0% None of the above factors J-1 VISA WAIVERS REQUESTED BY U.S. GOVERNMENT AGENCIES 9. 8. J-1 visa waivers may also be requested by interested U.S. government agencies (e.g., Dept. of Agriculture, Appalachian Regional Commission, Dept. of Housing and Urban Development). Which of the following activities does your state conduct for interested government agencies’ requests for J-1 visa waivers for physicians in your state? (check all that apply) If you have any comments on the J-1 visa waiver program, such as the reasons for participation or nonparticipation, please enter them in the space below. (Attach separately if additional space is needed) 72% Prepare a letter from a state official when supporting the waiver 78% Verify that the request is for a 37% Track practice locations of the agencies’ J-1 visa waiver physicians 15% Monitor physician compliance with the conditions of the waiver 48% Provide assistance to facilities applying for U.S. government agencies’ J-1 visa waivers 7% Other (please explain) 10. Please include a copy of your state’s written policies, if any, regarding J-1 visa waivers for physicians, with your completed questionnaire. 33 states provided written policies Thank you for your assistance. When our study is complete, we will send you a copy of our report. This appendix contains the responses to questions we asked facilities that requested waivers of the J-1 visa foreign residence requirement for physicians. We sent the questionnaire to the facilities for 211 physicians who had their waivers requested through ARC, DOT, HUD, and USDA from 1994 to 1995 (determined on the basis of the date the agency received the waiver request). We analyzed the practice specialties and practice settings for the 150 physicians who were practicing on January 1, 1996, for the facilities listed on agency data. Table VI.2: Practice Settings of Waiver Physicians Practicing on January 1, 1996 DOT (n=2) ARC (n=38) HUD (n=29) USDA (n=81) Includes rural health clinics, mental health clinics, health department clinics, and other practice settings. DOT (n=2) ARC (n=38) HUD (n=29) USDA (n=81) This appendix contains information for each state showing (1) the identified physician need in the state (2) the number of physicians with waivers granted or in process, and (3) the number of physicians who received NHSC scholarships or federal loan repayment who were practicing in the state. We used the number of full-time-equivalent physicians identified by HHS as needed to remove primary care Health Professional Shortage Area designations in the state on December 31, 1995, because it is the primary measurement used by HHS and the requesting agencies to establish the need for physicians. Although physicians with waivers may also practice in designated Medically Underserved Areas, HHS does not remove this designation and, as a result, there is no dedesignation level to measure the need for physicians in the Medically Underserved Area. To measure the number of waiver physicians who would be practicing on December 31, 1995, or shortly thereafter, we used data from the requesting agencies and states on the number of waiver applications sent to USIA from 1994 to 1995. For the number of NHSC physicians in a state, we used the number of NHSC scholarship and loan repayment recipients who were practicing on December 31, 1995. This is a conservative number of NHSC physicians; however, because it does not include the number of physicians who were NHSC state loan repayment recipients practicing in shortage areas, which was not available by state from NHSC at the time of our review. As shown in table VII.1, the degree to which the identified physician shortage can be offset by the waiver physicians practicing in a state varied between the states. In addition, when combined with the NHSC physicians practicing there, the number exceeded the number of physicians needed to remove some states’ primary care Health Professional Shortage Area designations, while other states’ identified physician needs were not met by these two physician sources. NHSC physicians as a percent of identified need (continued) In addition to those named above, the following individuals made important contributions to this report: Sarah F. Jaggar, Issue Area Director; Susan Lawes, Senior Evaluator; Susie Anschell, Evaluator; Julie Rachiele, Technical Information Specialist; Evan Stoll, Computer Specialist; Jerry Aiken, Computer Specialist; Julian Klazkin, Senior Attorney; Stan Stenersen, Evaluator; Lisa DeCora, Intern; Kathleen Belfi, Support Services Technician; and William J. Carter-Woodbridge, Communications Analyst. Council on Graduate Medical Education. First Report of the Council, Vols. I and II. Washington, D.C.: U.S. Department of Health and Human Services, 1988. Council on Graduate Medical Education. Sixth Report: Managed Health Care: Implications for the Physician Workforce and Medical Education. Washington, D.C.: U.S. Department of Health and Human Services, 1995. Iglehart, John K. “The Quandary over Graduates of Foreign Medical Schools in the United States.” The New England Journal of Medicine, Vol. 334, No. 25 (1996), pp. 1679-83. Institute of Medicine. The Nation’s Physician Workforce: Options for Balancing Supply and Requirements. Washington, D.C.: National Academy Press, 1996. Mullan, F., and others. “Medical Migration and the Physician Workforce.” Journal of the American Medical Association, Vol. 273, No. 19 (1995), pp. 1521-27. Pew Health Professions Commission. Critical Challenges: Revitalizing the Health Professions for the Twenty-First Century. San Francisco: University of California San Francisco Center for the Health Professions, 1995. U.S. General Accounting Office. Health Care Shortage Areas: Designations Not a Useful Tool for Directing Resources to the Underserved. GAO/HEHS-95-200, Sept. 8, 1995. U.S. General Accounting Office. National Health Service Corps: Opportunities to Stretch Scarce Dollars and Improve Provider Placement. GAO/HEHS-96-28, Nov. 24, 1995. U.S. General Accounting Office. U.S. Information Agency: Inappropriate Uses of Educational and Cultural Exchange Visas. GAO/NSIAD-90-61, Feb. 16, 1990. U.S. General Accounting Office. U.S. Information Agency: Waiver of Exchange Visitor Foreign Residence Requirement. GAO/NSIAD-90-212FS, July 5, 1990. Whitcomb, Michael E. “Correcting the Oversupply of Specialists by Limiting Residencies for Graduates of Foreign Medical Schools.” The New England Journal of Medicine, Vol. 333, No. 7 (1995), pp. 454-56. The first copy of each GAO report and testimony is free. Additional copies are $2 each. Orders should be sent to the following address, accompanied by a check or money order made out to the Superintendent of Documents, when necessary. VISA and MasterCard credit cards are accepted, also. Orders for 100 or more copies to be mailed to a single address are discounted 25 percent. U.S. General Accounting Office P.O. Box 6015 Gaithersburg, MD 20884-6015 Room 1100 700 4th St. NW (corner of 4th and G Sts. NW) U.S. General Accounting Office Washington, DC Orders may also be placed by calling (202) 512-6000 or by using fax number (301) 258-4066, or TDD (301) 413-0006. Each day, GAO issues a list of newly available reports and testimony. 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Summary: GAO reviewed the extent to which state and federal agencies used waivers to meet physician shortages in medically underserved areas, focusing on: (1) how many foreign physicians with J-1 visas receive waivers, where they practice, and their medical specialties; (2) whether federal agencies and states effectively coordinate policies and procedures for granting these waivers; and (3) the extent to which foreign physicians who receive waivers comply with waiver requirements to practice in underserved areas. GAO found that: (1) the number of waivers for physicians with J-1 visas to work in underserved areas has risen from 70 in 1990 to over 1,300 in 1995; (2) requesting waivers for physicians with J-1 visas has become a major means of providing physicians for underserved areas; (3) in 1994 and 1995, the number of waivers processed for these physicians equaled about one-third of the total identified need for physicians in the country; (4) almost all of these waiver physicians have primary care medical specialties and they are practicing in 49 states and the District of Columbia; (5) nearly 30 federal and state agencies were processing waiver requests for physicians from hospitals, health centers, and other health care facilities by 1995; (6) among them, no agency has clear responsibility for ensuring that placement efforts are coordinated; (7) although the federal agencies are now working together informally, they still have differing policies, overlapping jurisdictions, and varying communication with the states; (8) the Department of Health and Human Services (HHS) believes that the physicians should return home after completing their training to meet the intent of the exchange visitor program, and the other agencies view the waiver provision as a means to secure physicians to meet the health care needs of their constituents; (9) while more than 9 of every 10 physicians whose waivers were processed between 1994 and 1995 were practicing at their locations in January 1996, controls are somewhat weak for ensuring that physicians continue to meet the terms of their agreements; (10) even when the physicians and facilities follow the agencies' rules, the rules do not restrict physicians from working with those segments of the population that already are adequately served; and (11) proposed regulations published by the United States Information Agency and developed in working with the informal interagency group, coupled with recent amendments to the Immigration and Nationality Act would address many of the coordination and compliance problems, but not all of them.