How to Hire International Medical Graduates with Ease by Ann Massey Badmus, Attorney at Law

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1 May 2011 How to Hire International Medical Graduates with Ease by Ann Massey Badmus, Attorney at Law According to an American College of Physicians monograph published in 2008, International Medical Graduates (IMGs) made up nearly 25% of the U.S. physicians in active medical practice and around 30% of all IMG physicians practiced in an internal medicine specialty or subspecialty. In 2010, nearly 28% of the internal medicine residency matches went to non-u.s. citizen IMG physicians. Since IMGs often require immigration sponsorship to work after training, many practices hesitate to employ them. However, given these statistics, the enormous shortage of physicians, and the high cost and lost revenue due to provider vacancy, most medical employers simply cannot ignore this pool of qualified physicians. With the right planning and guidance, astute employers can masterfully manage the immigration process and hire new IMGs with ease. 1. Determine Your Eligibility to Sponsor IMGs An employer's ability to sponsor an IMG depends upon the physician's current visa status. In general, any medical employer can hire and sponsor a physician who has an H-1B visa. As long as the employer agrees to comply with H-1B visa requirements (e.g. payment of a fixed salary equal to or greater than the prevailing wage) there are no restrictions as to the employer's organizational structure or practice location. However, employers who hire H-1B physicians from residency or fellowship programs must consider whether the employment date can start in July or in October. In other words, is the physician's employment exempt from the current year's H-1B visa number limits known as the H-1B cap? Consultation with a qualified immigration attorney is the easiest way to answer this question. To sponsor an IMG who has a J-1 visa, the employer's physical practice location must be in an underserved area as designated by the U.S. Department of Health and Human Services. If the practice location is not so designated, the employer may also qualify if a significant percentage of the patient base live in surrounding underserved areas. An experienced immigration attorney can help determine whether the facility meets this and other criteria to hire J-1 physicians. 2. Start Your Recruitment Campaign Early Early recruitment is the key to good immigration planning. In general, recruiting physicians just before they begin their final year of training will help you meet the government's immigration timelines as well as your staffing timelines. This is particularly true for the recruitment of J-1 physicians. For example, in July 2011, Anytown General Hospital has identified a stellar IMG entering his third year of internal medicine residency on a J-1 visa. This physician will require a waiver of the two-year foreign residency requirement (J-1 waiver) through the state Department of Health J-1 waiver program, which will accept J-1 waiver applications starting in October. Anytown General has finalized the contract with the physician and is working with an immigration lawyer to file the J-1 waiver application in October. By all indications, the physician will start work in July 2012 as planned. For H-1B physicians, timing is just as important. If you contract early enough, it is more likely the physician can work with you immediately after residency. In an example, Anytown General signs an H-1B physician just starting the final year of his fellowship training, which he completes on June 30, Anytown General is not a cap-exempt employer and the H-1B physician is currently employed with a cap-exempt employer. Consequently, Anytown General's H-1B sponsorship will be subject to the H-1B cap and if the 1

2 cap is filled before the H-1B application is submitted, the physician cannot start work until October 1, Fortunately, in December 2011, there are a few H-1B visas available under the H-1B cap. Therefore, Anytown General immediately applies for and receives an H-1B visa with an approved employment start date of May 15, Even though the physician will not actually start employment until July 1, 2012, this strategy works because employment can begin up to 60 days after the H-1B visa approved start date. Early recruitment and planning has assured that the position is filled on schedule. 3. Know the Contractual Requirements Generally, you can use the same contracts for IMGs as you do for other physicians. However, there are a few requirements specific to IMGs who require visa sponsorship. Both J-1 physicians and H-1B physicians must be paid a fixed salary that meets or exceeds the prevailing wage for similarly qualified physicians in the local area. Both must receive the same benefits and actual wages offered to other similarly qualified physicians employed by you. In addition, both must be placed on payroll within 60 days of the H-1B approved start date, regardless of whether they have hospital privileges. For J-1 physicians, contracts in general must have a minimum three-year term, cannot have non-compete clauses, and must specify the exact address of each practice location. Other contractual requirements may apply, depending upon state where the practice is located. To save time in contract negotiations and in the immigration process, an employer should have an immigration attorney review its proposed contract. Immigration rules are complex but workable. Considering the desperate need for physicians and the stiff competition for highly qualified physicians, medical employers who are willing to hire IMGs enjoy a distinct advantage. And, with strategic planning and expert assistance, engaging the services of these highly qualified providers can be painless. For immigration questions about hiring IMGs for your practice, you are invited to contact Ann Massey Badmus at The information provided in this article is intended to help you understand basic issues involved in the immigration process for IMGs, and are offered only for general informational and educational purposes. This information is not offered as, nor does it constitute legal advice or legal opinions. You should not act or rely upon the information in this article without first seeking the advice of an immigration attorney. Market Analysis: Orthopedic Surgery There are 29,570 board certified Orthopedists in the U.S. and 85% are over the age of 40. One in four Americans has an orthopedic impairment, and orthopedic complaints are the most common reason to seek medical care in the U.S. Private practice makes up the majority (81%) of orthopedic practice settings. Within the private orthopedic setting, 60% are in single specialty group practice, 31% in solo practice, and 9% in multi-specialty practice. Currently 4% of practicing orthopedists and 13% of orthopedic residents are women. The majority (68%) of orthopedic surgeons report completing one fellowship, 12% report completing two. Among the top fellowships are: o Sports Medicine o Hand Surgery o Spine Surgery o Total Joint o Adult Knee o Pediatric Orthopedics o Adult Reconstruction o Adult Hip o Trauma o Shoulder and Elbow Orthopedic surgeons perform an average of 32 orthopedic procedures each month. Among the 12 most frequently performed procedures, arthroscopy of the knee is most frequent. Spinal fusion or 2

3 re-fusion are the second most frequent. Rotator cuff repair and carpal tunnel release were also listed as frequent procedures. Average payer mix is 34% commercial insurance managed care (HMO or PPO), 19% private sources (private insurance and self-pay), 24% Medicare, 12% worker's compensation payments, 7% Medicaid and 4% pro bono. Demand for orthopedic surgeons will rise with the aging of the population, making Orthopedic Surgery one of the most sought after physician specialties. If you need Orthopedic Surgery compensation and recruitment incentive data or assistance with recruiting an orthopedic surgeon, please contact us. Sources: American Academy of Orthopedic Surgeons, Journal of Bone & Joint Surgery, Beckers ASC Report Top 6 Tips to Compete for Primary Care Providers Your organization may have firsthand experience with the high demand for primary care providers (PCPs). But you should expect the demand to increase further as more PCPs retire and as 30 million uninsured Americans are added to the system through healthcare reform. If you follow these recommendations, you will be better prepared to compete for top choice candidates. 1. Start Early Strategic and recruitment plans should allow ample time to recruit PCPs: Family Physicians: 6 12 months Pediatricians: 6 12 months General Internists: months Geriatricians: 9 18 months Advanced Practice Providers: 4 8 months If the practice location is rural, allow an additional three months because the candidate pool for those opportunities will be smaller. Add another 2 3 months for experienced providers to relocate. Add up to 12 months or more for residents or fellows to complete their training and relocate. 2. Be Prepared to Begin the Search When planning to recruit PCPs to your organization, you will attract more candidates if you are well prepared. Make sure you have adequate space and staff for the new provider. Plan to have some of your existing patients transfer to the new provider or offer to assist the new provider in building his/her practice. Prepare a letter of intent and employment contract so you can make an offer quickly. Financially prepare to pay the provider's first year salary or guarantee. 3. Offer Flexible Work Schedules and Recruitment Incentives A thorough interview will help identify the issues and incentives most important to each candidate. Flexibility, creativity and customization of these incentives will make the difference in your hiring successes: Opportunity to work part-time or full-time based on family needs Signing bonus ranging from $5,000 to $25,000 or more for PCPs Education loan repayment (graduating physicians average $145,000 in debt) Relocation assistance of $3,000 to $10,000 or more Stipend of $1,000 to $1,500 per month during the last 12 months of training 3

4 4. Recognize Your Competition is National, Not Local With the use of the internet, your recruitment competition is no longer just the group next door or the hospital down the street. By turning on their smart phones or computers, providers can quickly see opportunities all over the country posted on job boards and social media sites as well as those that come directly into their inbox. 5. Evaluate Adding an Advanced Practice Provider Your organization may be well served by adding a Nurse Practitioner or Physician Assistant instead of a physician, particularly if you need a PCP in 3 6 months. Hiring a PA or NP can favorably affect the profitability of a hospital or medical practice. Primary care advanced practice providers can receive % of physician fees for services provided. Compensation surveys report median primary care PA and NP salaries in the $85,000 95,000 range. Staffing with PAs or NPs allows your physicians to manage patients with complex medical problems while advanced practice providers manage routine patient care such as health history, physicals, diagnosis and treatment. For more information regarding advanced practice providers, please contact us. 6. Use a Locum Tenens Provider While You Recruit a Permanent Provider If you are understaffed or your current PCPs are overworked and tempted by offers from competing organizations, consider adding a locum tenens physician or advanced practice provider. This will help retain current providers and patients while giving you the time and flexibility to hire a top choice candidate. For more information regarding locum tenens services, please contact us. To request a copy of our Primary Care Provider White Paper, please contact us. Do Your Staffing Plans for Healthcare Reform Include Locum Tenens? You are likely preparing for changes the Patient Protection and Affordable Care Act (PPACA) will bring in You may be evaluating electronic health record (EHR) systems and accountable care organizations (ACOs), and wondering how meaningful use will impact your hospital or medical group. With over 30 million newly insured patients, provider recruitment will be a priority. Provider recruitment can be quite challenging and take months to hire a new provider. It may take even longer if the credentialing process is not completed in a timely manner. During the recruitment process, waiting rooms and emergency rooms continue to fill with patients who need immediate medical attention. While your physician recruitment project is underway, consider locum tenens as a cost effective staffing solution. In the past, locum tenens providers filled staffing needs for vacations, medical leaves of absence and CME. Now, locum tenens providers are also assisting medical groups and hospitals during the provider recruitment process. Many well trained residents and fellows provide locum tenens prior to accepting a permanent position. This enables them to experience working in a hospital, single/multi-specialty group, or community health center before making their decision to permanently commit to a practice. Those without a geographic preference may choose locum assignments in rural, suburban and metropolitan areas and see which they prefer. It is not unusual for a locum tenens provider to eventually accept a permanent position with a facility where they provided locum coverage. Utilizing locum tenens providers could lead you to the permanent provider you were seeking all along! For more information on locum tenens coverage, please contact us. 4

5 Compensation Corner Internal Medicine-Pediatrics East $193,000 West $206,000 South $199,000 Midwest $201,000 Pediatric Intensive Care East $234,000 West $261,000 South $274,000 Midwest $277,000 Colon & Rectal Surgery East $352,000 West $369,000 South $362,000 Midwest $346,000 Brought to you by: 2038 Caribou Drive Ste 201 Fort Collins, CO Subscribe to this newsletter (We will not share your address with third parties) Focus Physician Recruitment. All Rights Reserved. 5

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