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After Training: Options for FMGs Connie Berry, Manager Texas Primary Care Office January 13, 2009.

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Presentation on theme: "After Training: Options for FMGs Connie Berry, Manager Texas Primary Care Office January 13, 2009."— Presentation transcript:

1 After Training: Options for FMGs Connie Berry, Manager Texas Primary Care Office January 13, 2009

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9 Proposed State Legislation Senate Bill 86 Filed early, would require any physician who is not a US citizen or Permanent Resident to work in a shortage or underserved area. This mirrors New York law, which also has provisions for the state to designate facilities, such as teaching and charity hospitals as serving the underserved. Why is this being proposed? To obligate all foreign physicians trained in the US to serving the underserved. Addresses the issue of a service obligation for physicians who enter and train on the H1-B visa.

10 J-1 Definitions: Temporary non- immigrant Sole intent - educational training Automatically subject to 212(e) of the Immigration and Nationality Act (2 year Home Residency Requirement) H1B Definitions: Temporary specialty worker Employment based (training) Teaching hospital = employer “Dual intent” (acceptable to express interest in immigrating) USMLE Step 3 required No home residency requirement Differences Between J-1 and H1B Visa

11 J-1 Benefits: USMLE Step 3 NOT required Low cost for IMG & program Simple processing Seven years of eligibility Accurate tracking of physicians Monitored training progression Spouse work authorization Available for HPSA, MUAs US diplomacy/International exchange H1B Benefits: Competitive selection (considered more attractive to applicants) Moonlighting permitted if part of job description Post training recruiting tool for hospitals Ability to apply for permanent resident status/citizenship Differences between J-1 and H1B Visas

12 J-1 Drawbacks: Generally ineligible for recruitment by teaching hospital after training No moonlighting permitted Subject to return home/212(e) H-1B Drawbacks: Expense for IMG/hospitals –Attorney fees, prevailing wage etc. Increasing responsibilities imposed on GME programs/teaching hospitals Only 6 years of eligibility Spouse – no work authorization Lack of accurate H-1 physician data Differences between J-1 and H1B Visa

13 General J-1 shortcomings  214(b) Non-immigrant intent Increasingly more difficult for IMGs to prove Rise in visa denials  212(e) IMGs – 2yr home requirement Considered a disadvantage for IMGs and programs that may be interested in recruiting trainees Declining interest in waivers to practice in medically underserved areas/primary care Perception that J-1 is less competitive General H-1B shortcomings Rising costs for hospitals and IMGs Ineffective interagency tracking No service obligation in US or home country Wide variability in institutional policies, practices, resources Concerns over regulatory compliance Immigration reform -increased liability for hospitals Differences between J-1 and H1B Visa

14 Immigration Process: Both visa types require either Labor Certification or National Interest Waiver to obtain Legal Permanent Residence Differences between J-1 and H1B Visa

15 Does the Conrad 30 Program work? Texas “Where are they now?” analysis Texas “Where are they now?” analysis 71 physicians recommended for a waiver in Texas have completed their obligation 71 physicians recommended for a waiver in Texas have completed their obligation 120 are currently under their 3-year obligation 120 are currently under their 3-year obligation Of the completers: Of the completers: 56.3% still in the same city 56.3% still in the same city 77.5% still in the same county 77.5% still in the same county 88% recommended for Lower Rio Grande Valley are still there 88% recommended for Lower Rio Grande Valley are still there 91% are still in Texas! 91% are still in Texas!

16 Is it Perfect? NO! NO! Two-sides to every complaint Two-sides to every complaint Parallel to any professional with an obligation– National Health Service Corps, Military docs, State Loan Repayers Parallel to any professional with an obligation– National Health Service Corps, Military docs, State Loan Repayers Myths, Rumors and Really Old Stuff Myths, Rumors and Really Old Stuff “Barter”-- trading service of staying. Who’s giving and who’s getting the most? “Barter”-- trading service of staying. Who’s giving and who’s getting the most?

17 What do people want? States– Docs for underserved areas and populations States– Docs for underserved areas and populations Employers– Income generator, but not future competition Employers– Income generator, but not future competition Waiver physicians– More freedom! More choices! More money! Waiver physicians– More freedom! More choices! More money!

18 Texas Conrad 30 J-1 Visa Waiver Program Responsibilities and Rights

19 Waiver as Opportunity and Transition Going from Residency or Fellowship training, into private practice is a transition. The employment settings, public compared to private practice, are very different. We have developed these Rights and Responsibilities for the Physicians and their Employers, to help make the transition a success for both.

20 J-1 Visa Waiver Physicians Responsibilities and Rights I am Responsible for respecting my employer’s offer of employment I am Responsible for respecting my employer’s offer of employment An offer of employment is a serious commitment, with immediate and long term financial implications. The employer is also committing their personal and professional time and practice support. These obligations have value, both financial and intrinsic. Accepting the offer of employment should recognize and respect the value of the offer.

21 J-1 Visa Waiver Physicians Responsibilities and Rights I am Responsible for asking for clarification of any contract terms I do not understand I am Responsible for asking for clarification of any contract terms I do not understand Contract language can be confusing, even if English is your first language. BEFORE SIGNING a contract, ask about anything you don’t understand or ask to have an opportunity to have someone with contract expertise, review it with you.

22 J-1 Visa Waiver Physicians Responsibilities and Rights I am Responsible for practice performance that exceeds my sponsor’s level of investment I am Responsible for practice performance that exceeds my sponsor’s level of investment Productivity, such as the number of patients seen each day, is one measure of performance. The physician and employer can discuss marketing and scheduling to increase productivity. This is not a 9 to 5 job.

23 J-1 Visa Waiver Physicians Responsibilities and Rights I am Responsible to my employer to request approval for any outside employment and gain appropriate work authorization I am Responsible to my employer to request approval for any outside employment and gain appropriate work authorization Moonlighting or working for another employer is only OK if the primary employer approves. The outside employment may conflict with the primary job.

24 J-1 Visa Waiver Physicians Responsibilities and Rights I am Responsible for treating every patient, staff member and affiliate with the utmost respect and dignity without regard to race, gender, education, ethnicity or religion I am Responsible for treating every patient, staff member and affiliate with the utmost respect and dignity without regard to race, gender, education, ethnicity or religion Understanding the culture of the patients, peers, co-workers and community is important for success, whether in the obligated position or in developing skills for remaining in the US. Non- discrimination is the law in the US, but it’s also our expectation for respect for diversity.

25 J-1 Visa Waiver Physicians Responsibilities and Rights I am Responsible for behaving in a professional manner as is expected of a physician I am Responsible for behaving in a professional manner as is expected of a physician Expectations for a good work ethic and attention to professional standards, such as charting and documenting services you provide are not negotiable. Meet with your employer and peers regularly and join physician associations to further continuing education and expectations.

26 J-1 Visa Waiver Physicians Responsibilities and Rights I am Responsible for knowing and acting as though my conduct is a reflection of the practice, because it is I am Responsible for knowing and acting as though my conduct is a reflection of the practice, because it is Be mindful of how your behavior is viewed by others in your community. Be sure that your family knows they are seen as an extension of you and the practice your are associated with.

27 J-1 Visa Waiver Physicians Responsibilities and Rights I have a Right to be treated equal to my peers I have a Right to be treated equal to my peers Your obligation doesn’t make you an “indentured servant.” Negotiate with your employer about equal treatment as far as taking call, etc. Remember also sometimes the newest doc gets the least choice in schedules or duties.

28 J-1 Visa Waiver Physicians Responsibilities and Rights I have a Right to be compensated as agreed in the employment contract I have a Right to be compensated as agreed in the employment contract The contracted salary is part of the agreement that allowed the waiver recommendation. If you sign a new contract, it may not meet the requirements for the waiver. This may also limit your right to ask for a much higher salary.

29 J-1 Visa Waiver Physicians Responsibilities and Rights I have a Right to expect all billings submitted for my services will be lawful and correct I have a Right to expect all billings submitted for my services will be lawful and correct Ask questions, ask to verify billings submitted under your ID number and license. You can be liable for any errors or unlawful submissions.

30 J-1 Visa Waiver Physicians Responsibilities and Rights I have a Right to regular performance meetings to avoid work issues from escalating I have a Right to regular performance meetings to avoid work issues from escalating Meet regularly with your employer and other key staff (Director of Nursing!) to be sure that any problems are addressed. This will also let you know whether your performance is on track with your employer’s expectations.

31 J-1 Visa Waiver Physicians Responsibilities and Rights I have a Right to discuss my situation with legal or government professionals if necessary I have a Right to discuss my situation with legal or government professionals if necessary If issues with your contract or employment concern you, our office can talk with you and advise you about possible solutions.

32 J-1 Visa Waiver Physicians Responsibilities and Rights I have a Right to leave the practice with no repercussions after my obligation is complete I have a Right to leave the practice with no repercussions after my obligation is complete Be sure that you have been open with your employer about your future plans. If you successfully complete your obligation and the contract terms, you should be able to practice more independently. Be aware of any non- solicitation clauses in your contract and abide by them, and also be aware of Immigration regulations and opportunities. For example, getting a “green card” or permanent residency will require employment that meets USCIS requirements.

33 Responsibilities and Rights of Physicians who Employ a J-1 Visa Waiver Physician I am Responsible for fair and equitable treatment, without regard to visa status, race, gender, education, ethnicity or religion I am Responsible for fair and equitable treatment, without regard to visa status, race, gender, education, ethnicity or religion

34 Responsibilities and Rights of Physicians who Employ a J-1 Visa Waiver Physician I am Responsible for timely salary payment as agreed in the employment contract I am Responsible for timely salary payment as agreed in the employment contract

35 Responsibilities and Rights of Physicians who Employ a J-1 Visa Waiver Physician I am Responsible for upholding all other terms of the contract. Any re- negotiations must meet Visa Waiver Requirements I am Responsible for upholding all other terms of the contract. Any re- negotiations must meet Visa Waiver Requirements

36 Responsibilities and Rights of Physicians who Employ a J-1 Visa Waiver Physician I am Responsible for clearly stating my performance expectations and providing assistance for reaching these goals I am Responsible for clearly stating my performance expectations and providing assistance for reaching these goals

37 Responsibilities and Rights of Physicians who Employ a J-1 Visa Waiver Physician I am Responsible for setting the example of professionalism that I hold others to I am Responsible for setting the example of professionalism that I hold others to

38 Responsibilities and Rights of Physicians who Employ a J-1 Visa Waiver Physician I am Responsible for meeting regularly to resolve issues in the workplace or agreement I am Responsible for meeting regularly to resolve issues in the workplace or agreement

39 Responsibilities and Rights of Physicians who Employ a J-1 Visa Waiver Physician I am Responsible for assuring “clean” and legal billings on behalf of my clinic and employees I am Responsible for assuring “clean” and legal billings on behalf of my clinic and employees

40 Responsibilities and Rights of Physicians who Employ a J-1 Visa Waiver Physician I have the Right to expect compliance with contracted service and benefits I have the Right to expect compliance with contracted service and benefits

41 Responsibilities and Rights of Physicians who Employ a J-1 Visa Waiver Physician I have the Right to be notified of any outside employment I have the Right to be notified of any outside employment

42 Responsibilities and Rights of Physicians who Employ a J-1 Visa Waiver Physician I have the Right to be respected for my agreement to employ this physician I have the Right to be respected for my agreement to employ this physician

43 Responsibilities and Rights of Physicians who Employ a J-1 Visa Waiver Physician I have the Right to be consulted over any decisions that may impact my role as an employer I have the Right to be consulted over any decisions that may impact my role as an employer

44 Responsibilities and Rights of Physicians who Employ a J-1 Visa Waiver Physician I have the Right to discuss financial implications of the employee or their behavior I have the Right to discuss financial implications of the employee or their behavior

45 Responsibilities and Rights of Physicians who Employ a J-1 Visa Waiver Physician I have the Right to expect fully professional behavior and conduct on the part of the sponsored employee I have the Right to expect fully professional behavior and conduct on the part of the sponsored employee

46 Good Luck! Please let us know if you have any questions. We are open to talking with physicians and employers, whether or not they are in Texas or plan to work in Texas. We know when a lawyer might be a better resource, we are not immigration specialists. Contact: Clay Daniel, or (These slides will be posted on our website:


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