When the isolated Appalachian community of Grantsville, W.Va., was forced to padlock the emergency room at its county-operated Calhoun General Hospital for 100 days in 1995 because there were no physicians, local healthcare leaders feared the end of the community's access to inpatient care.
"Rural healthcare in the area was on the verge of collapse. The hospital had closed, the clinic had no physicians and recruiting was difficult," says Barbara Lay, chief executive officer of Minnie Hamilton Health Care Center, a primary-care clinic next door to the struggling acute-care facility.
With state assistance, Minnie Hamilton took over operation of Calhoun General in 1996 and converted the facility into a 43-bed critical-access hospital. It then recruited eight foreign physicians; they helped the hospital post net income of $12 million in 2003.
The physicians were able to come in large part because of a federal initiative known as the J-1 visa program, which gives qualified international medical graduates the opportunity to legally remain in the U.S. if they commit to practice for three years in a medically underserved area. States are permitted to apply for up to 30 physicians each year through the program.
"The facility simply would not exist without it," Lay says of J-1.
The visa initiative is one of several federal programs rural and urban providers have been increasingly relying on to recruit talent from abroad at a time of growing U.S. health-labor shortages. But changes in immigration policy in recent years, particularly after the Sept. 11, 2001 terrorist attacks, are ushering in a new set of challenges for healthcare organizations that depend on qualified foreign-born physicians, nurses and other clinicians to meet their growing patient needs.
Of chief concern to providers is the J-1 visa program's June 1 expiration date, as well as the Department of Homeland Security's "VisaScreen" regulations slated to take effect July 26. The healthcare industry contends the latter program creates burdensome requirements for providers that will limit their ability to employ foreign-born nurses, therapists and other healthcare professionals.
According to data from the U.S. Census Bureau, 1.1 million immigrants account for 13% of U.S. healthcare professionals, and the percentages are rising. A quarter of all physicians are foreign-born, as are 17% of nurses, 16% of clinical laboratory technicians and more than 11% of registered nurses, according to a report by the Immigration Policy Center in Washington. During the 1990s, immigrant employment grew by 114% in home healthcare, 72% in nursing-care facilities and 32% in hospitals, the report said.
In 2003, 1,027 physicians began work at U.S. healthcare organizations through the J-1 visa program, according to aides of Rep. Jerry Moran (R-Kan.), who in April introduced legislation to reauthorize the J-1 program for five more years. That bill has been marked up in a House subcommittee this month.
Five of the eight physicians recruited by Minnie Hamilton over the past decade have also elected to remain at the hospital, led by the facility's medical director, Vishwanath Hande, who joined the facility in 1996 on a J-1.
"Minnie Hamilton has benefited enormously by having us come here and essentially save the hospital," says Hande, a native of India who is pursuing his subspecialty interest in pulmonology and is launching new patient-care initiatives at the hospital, including a sleep laboratory.
Foreign-born physicians like Hande have generally experienced a swifter approval process for entering the U.S. than other foreign healthcare professionals who may face additional three- to six-month delays in obtaining temporary work permits known as H-1B, H-1C and TN visas, once the federal VisaScreen regulations take effect. The new regulations, which are an immigration and not licensure issue, implement part of a 1996 immigration law that requires foreign healthcare workers including nurses, medical technologists, physician assistants, and physical, occupational and speech therapists to receive a certificate authenticating their English proficiency, educational transcripts and work license. For several years, the VisaScreen requirement has been temporarily waived for foreign-born healthcare workers who are seeking U.S. positions, but that is about to change.
Starting next month, the certification requirements will extend to nurses and other health workers who have been practicing in the U.S. on temporary visas, even if they've been licensed here for years. They will be required to take the National Council of State Boards of Nursing's licensure examination or a similar exam for the VisaScreen certification, says immigration lawyer Carl Shusterman. "A lot of hospitals appear to think that the VisaScreen applies to new hires and don't realize they could lose people who are already on staff," he says.
Carla Luggiero, senior associate director of federal regulations for the American Hospital Association, says the requirement will have "significant impact" on hospitals and their ability to staff their facilities. Fourteen senators, the AHA and other provider organizations have been lobbying Homeland Security Secretary Tom Ridge to delay the effective date of the VisaScreen final rule until July 2005.
AHA Executive Vice President Rick Pollack said the VisaScreen requirement is appropriate and fair to impose on future foreign-born healthcare workers entering the U.S. but "redundant and unnecessary" for foreign-born healthcare professionals who have graduated from U.S. training programs and passed requisite exams establishing that they have met minimum standards for safe practice.
The national council estimates that as many as 15,000 licensed immigrant nurses now practicing in the U.S. may not be able to continue to work if they cannot obtain VisaScreen certification by July 26, including several thousand Canadian nurses who commute across the border daily.
Barbara Nichols, CEO of the Commission on Graduates of Foreign Nursing Schools, which is recognized by statute as a credentialing organization for foreign healthcare workers, says implementation of the VisaScreen regulation stands to considerably interrupt healthcare in states bordering Canada.
"When this regulation's final rule was issued in July of 2003, it wasn't clear that Canadian nurses were swept into this," she says, adding that the commission put out a field advisory on the immigration rule in January of 2004. "Hospital CEOs don't sit around and read the Federal Register. There are a lot of anomalies to this that no one ever contemplated; it's the poster child of unintended consequences," Nichols says.
