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. 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. 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. 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. 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. 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. 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. 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. 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. 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). 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. 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.

Summary: 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. 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.