VISA Programs: Do They Help In Primary Care and Rural Areas?
Robert C. Bowman, M.D.
- J-1 Visa Waiver physician data is largely missing in action and
monitoring is spotty, according to the GAO.
- J-1 Visa Waiver physicians appear to make important contributions to
rural underserved and to urban underserved areas. Contributions can involve
primary care and specialty care areas.
- The best estimates of J-1 Visa Waiver physicians involve international
medical graduates in office based internal medicine. This is the group with
the best rural and underserved distributions. IMGs not in internal medicine
or office based care make lower levels of contributions to rural and to
underserved areas.
- IMG office internal medicine is a group that has slightly greater rural
choice, but has significantly higher underserved and isolated location. This
is an indication of the J-1 Visa effect. Without this J-1 requirement, the
remaining rural component may be reduced greatly. This is a concern if the
J-1 program is bypassed or if positions are shifted to other states and
locations that are in less need.
- The 2% of the nation's workforce that involves international born IMG
office internal medicine physicians contribute 4.9% of the total rural
underserved workforce of the nation and 3.9% of the urban underserved
workforce. 91.2% of underserved contributions are made by other physicians.
- 2% Solutions Compared - Rural born family physicians are 2% of total
physicians and IMG office internal medicine physicians are also about 2% of
the nation's workforce. This allows comparisons of each to be made on a head
to head basis below. IMG IM physicians have a consistent 6% underserved
contribution in rural and urban areas and 3 times the national average for
the isolated underserved areas. Rural born FPGP physicians had 2 to three
times higher levels of all rural distributions compared to IMG IM with the
exception of isolated underserved where the advantage was narrowed to 2.4%
to 1.5%. Rural born FPGP physicians are a concentrated source of military
family medicine also and military obligations may compete with rural and
with underserved workforce. Leveling
- Family medicine is about 15% of the nation's workforce and contributes
26% of the nation's urban underserved workforce and 38% of the rural
underserved workforce. IMG family physicians were less than 0.7% of the
total workforce and they had lower levels of distribution than US born
family physicians or IMG internal medicine physicians.
- Gold standards for Urban Underserved Distribution - Black, Mexican
American, Hispanic, Puerto Rican, and Native American family physicians are
about 3.4% of the nation's total workforce and contribute 13% of the urban
underserved workforce and 7.9% of the nation's rural underserved workforce
total. This was about 10,000 total physicians for the 1987 - 1999 cohort
from all medical schools. The Inner City FM residency training programs
distribute to urban underserved at even higher rates, indicating some
training program impact.
- Indexes of Concentration For Underserved Areas beyond Composition in the
Workforce - The composition of urban underserved workforce proportion
divided by the proportion of physician workforce is 3.78 for these diverse
family physicians. The urban underserved contributions of IMG office
internal medicine are 1.97 times their composition in the workforce. The
distribution indexes for all family physicians are much the same as IMG
office IM, even with the obligations.
Distribution: Index The
distributions for family physicians also remain constant over decades.
- Retention in Primary Care - Retention factors are highest for family
physicians for all locations outside of major medical centers. Family
physicians remain in FM at 98% and office primary care at 90% and outside of
major medical centers at 50% or above. International born IMG office IM
physicians do appear to maintain the underserved distributions shown for the
1987 - 1995 graduates. Earlier comparisons are difficult due to changes in
immigration. Later comparisons involve IMG physicians still in training.
- Limitations By Differences - IMG physicians are limited in distributions
by a number of factors related to differences, adjustments, and types of
training. Preparation is not as likely to focus on preparation for practice
outside of major medical centers and in rural areas.
- Advantages in Certain Locations - IMG physicians clearly have advantages
in some of the diverse populations in the United States. Rural born family
physicians are more likely to train in medical schools and programs that
were more specific to rural locations. Rural birth is a factor in a number
of interactions with patients and community.
| |
Total 1987 - 1999 Class Years Workforce |
Urban Under-served |
Rural Under served |
All Rural |
Rural Not MMC |
Major Medical Center |
Isolated Rural |
Isolated Under served |
Military |
|
US Population 2000 |
|
10.7% |
7.1% |
20.0% |
17.2% |
33.7% |
4.2% |
2.0% |
0.7% |
|
National Averages |
100.00% |
3.0% |
2.7% |
9.8% |
7.2% |
73.4% |
1.1% |
0.40% |
1.8% |
|
Deficit Ratio |
1 |
0.28 |
0.38 |
0.49 |
0.42 |
2.18 |
0.26 |
0.20 |
2.57 |
|
Black,Hispanic,Native FP |
3.40% |
11.8% |
6.6% |
12.9% |
11.1% |
52.4% |
1.5% |
0.6% |
2.0% |
|
Rural US Born FPGP |
2.01% |
3.2% |
12.3% |
41.7% |
35.2% |
40.2% |
6.7% |
2.43% |
6.8% |
|
Foreign Born IMG Off IM |
1.97% |
5.9% |
6.7% |
14.4% |
12.3% |
60.4% |
2.2% |
1.45% |
0.5% |
Distribution: Index Concentrations of
Physician Distribution - compare and contrast the various types that
distribute to rural underserved and urban underserved locations. How do
international medical graduate internal medicine physicians compare to family
physicians? What does birth origin have to do with practice location?
Preliminary Findings on the Use of J-1 Visa Waivers to Practice in
Underserved Communities GAO
http://www.gao.gov/new.items/d06773t.pdf Visa waiver programs are increasing in numbers and importance and generally
contribute more than NHSC programs although state to state variation is common.
Generally the most urban states use waivers the most. The "least desirable"
states and those without training programs in close proximity to needs have more
difficulties filling the waivers. Visa waiver physicians are not always
monitored. No federal agency tracks actual underserved locations or
contributions, which remain largely unknown. About 75% of practice location
waivers were to allow hospital practice. States requested waivers to insure that
J-1 Visa physicians would actually serve the underserved. 14 states feared that
giving up unused Visa permits would allow IMGs to wait until the Visa permits
were redistributed to larger states considered more desirable. One state noted
that it had fewer takers when the Conrad limit was increased from 20 to 30 in
2002. States can use up to 5 positions of their 30 allotment to address needs
outside of underserved areas. This level was considered adequate by 27 states.
More Data Needed on J-1 Visa Waiver contributions with repetition of much of
the above
http://www.gao.gov/new.items/d0752.pdf Also various violations of the
waivers were reported including IMGs not showing up to work, leaving locations
without permission, or practicing outside of approved specialty or location.
Relatively few violations were reported but monitoring was reported as low and
constrained by low budgets for monitoring and supervision of all such
activities.
Strategies for Addressing Potential Losses of IMGs
http://www.shepscenter.unc.edu/research_programs/rural_program/fb66.pdf
What Could Have Been: Maximal Primary Care
Training Capacity
Physician Workforce Studies
www.ruralmedicaleducation.org