by John K. Iglehart Professional and political concern about the increasing numbers of graduates of foreign medical schools entering U.S. residency programs has re-emerged during the past year. Previous attempts to limit the number of such graduates who fill residency positions have been thwarted by a practical but serious problem: who will care for the millions of people, many of whom are poor, in inner cities and rural communities, if the institutions serving these areas are unable to recruit foreign-trained physicians for the residencies and staff practices that are generally shunned by graduates of American medical schools? In this report, I will discuss the controversies surrounding the growing number of graduates of foreign medical schools, including the reluctance of the Clinton administration and many members of Congress to reduce the opportunities for these persons to train and practice here. Graduates of foreign medical schools represent about 23 percent of actively practicing physicians in the United States (Table 1 not shown). These physicians fill an increasing number of U.S. residency training positions ? the required gateway to medical practice in this country ? and a majority of them remain here.1 Three categories of such physicians participate in residency programs in the United States: citizens of other countries who are in the United States on temporary visas (H-1B or J-1 visas), immigrants who are naturalized American citizens or have permanent-resident status, and native-born American citizens who graduated from foreign medical schools and have returned to the United States for advanced training. Between 1988 and 1994, the number of graduates of foreign medical schools entering U.S. residency training programs more than doubled, from 2201 to 5891 (Table 2 not shown). Since the early 1980s, the number of graduates of U.S. medical schools has remained stable, at about 17,000 a year. Medicare and Graduate Medical Education Graduate medical education is financed through public and private revenues from third-party payments for medical care. Medicare, the federal health insurance program for the elderly and disabled, is a crucial source of funding for teaching hospitals, because it makes payments for graduate medical education and sets no limits on the number of residents it will support. The largest explicit source of funding for graduate medical education, Medicare makes direct medical-education payments to hospitals for residents' stipends, faculty salaries, related administrative expenses, and institutional overhead allocated to residency programs, as well as an indirect medical-education adjustment to per-case payments. The indirect adjustment is meant to compensate teaching hospitals for the increased costs attributable to the involvement of residents in patient care and the severity of conditions in patients requiring the specialized services that teaching hospitals provide. In 1995, Medicare provided $2 billion in direct medical-education payments and $4 billion in indirect payments. Both sets of payments are based on the number of residents being trained in a hospital: the more residents, the higher the payments. Some teaching hospitals have responded to financial pressures by increasing the number of residency positions and, hence, their revenues. These Medicare monies also finance substantial amounts of medical care, much of it for people who are poor but not among the program's 34 million beneficiaries. In a recent speech, Dr. Philip R. Lee, assistant secretary for health and scientific affairs in the Department of Health and Human Services, stated, We know that in some institutions, particularly in New York and New Jersey, residents are being used, and these are largely or almost exclusively foreign medical graduates, to provide cheap care for poor people. It's a way to subsidize care through residency training and not actually fund the real costs.2 Attempts to Reduce Medicare Support Over the past decade, there have been a number of unsuccessful attempts to reduce Medicare support for graduates of foreign medical schools in U.S. training programs. In 1985, Senator Robert Dole (R-Kans.) and two colleagues introduced legislation that would have terminated Medicare payments for residency positions filled by graduates of foreign medical schools who were not U.S. citizens3; the measure was never enacted. During the debate over health care reform in 1993 and 1994, proposals supported by the Clinton administration and several congressional committees called for a strict limit on the number of physicians allowed to enter residency programs (110 percent of the number of graduates of U.S. medical schools). This stricture, which would have effectively closed U.S. training positions to all but a few graduates of foreign medical schools, had been recommended to Congress by the Physician Payment Review Commission and the Council on Graduate Medical Education.4,5 The reform died, with no legislation enacted. The fiscal-year 1997 budget that the Clinton administration has submitted to Congress proposes a freeze on the current number of residencies supported by Medicare, a measure advocated by Dr. Kenneth I. Shine, president of the Institute of Medicine.6 It is uncertain whether Congress will act on this proposal in 1996. In 1995, as part of the Republican effort to balance the federal budget, Congress again considered reducing Medicare support for residency positions filled by graduates of foreign medical schools. Testifying before the Senate Finance Committee in July on behalf of the Association of American Medical Colleges, its president, Dr. Jordan J. Cohen, said: While the association should consider all available options for addressing this oversupply [of physicians], it should ? first and foremost ? pursue options to diminish the number of international medical graduates pursuing graduate medical education in the United States and remaining in the United States following the completion of their graduate training.7 Senator Daniel Patrick Moynihan of New York, the committee's ranking Democrat and former chairman, took exception to Cohen's testimony and made a strong case for maintaining the status quo, arguing, "The number of residents is, and should be, a function of medical science." On October 19, the House voted to reduce Medicare support for graduates of foreign medical schools with only temporary visas. As the year wore on, however, congressional support for such actions waned. Finally, in November, a House-Senate conference committee, meeting to reconcile differences in Republican-sponsored budget bills approved by the two chambers, eliminated a provision that would have reduced Medicare payments to teaching hospitals for residency positions filled by graduates of foreign medical schools. Kenneth E. Raske, president of the Greater New York Hospital Association, declared the action a major victory for the association's members and credited Senator Alfonse M. D'Amato and Representative Susan Molinari, both New York Republicans. On December 6, 1995, President Clinton vetoed the entire budget bill, thus ending the yearlong Republican effort to reform Medicare.8 The Political Arena A wide variety of private and public interests, many with competing agendas, are represented in the debate over graduates of foreign medical schools, including teaching hospitals and their Washington, D.C., lobby, the National Institutes of Health and other biomedical research centers, other federal and state agencies, legislators, professional medical associations, accrediting bodies, and immigration lawyers. The academic community itself is divided. Whereas the Association of American Medical Colleges favors strict limits on the entry of foreign-trained physicians into residency positions, other academic groups oppose measures that restrict the number of scientists from other countries who are allowed to immigrate.9,10 Most of these parties, including Congress, do not consider the question in the context of the overall supply of physicians. Instead, they address narrow interests, such as expanding residency positions to generate revenue and provide service, staffing rural practices, or pressing the legal cases of individual doctors seeking entry into the United States. The processing of the exchange-visitor visas for which graduates of foreign medical schools apply exemplifies the involvement of several federal agencies with different agendas. The U.S. Information Agency administers the exchange-visitor program and grants J-1 visas. Applicants must be guaranteed employment by an accredited educational institution, such as a teaching hospital, university, or the National Institutes of Health, before a visa is granted. All graduates of foreign medical schools must also obtain certification by the Educational Commission for Foreign Medical Graduates, which approves the credentials of graduates of some 900 foreign medical schools in approximately 130 countries. In 1994, the largest numbers of certificates were granted to doctors from India (accounting for 25.9 percent of the certificates granted), the Philippines (8.1 percent), Pakistan (5.9 percent), the countries of the former Soviet Union (4.2 percent), China (3.7 percent), and Egypt (2.6 percent). U.S. citizens, principally from medical schools in the Dominican Republic, Grenada, Mexico, and Montserrat, were granted 4.9 percent of all certifications in 1994. On completion of their work or training, exchange visitors are required to return to their native countries for a minimum of two years before attempting to return to the United States on a permanent basis. This requirement can be waived, however, under circumstances deemed exceptional, if the waiver is requested by another federal agency. Since 1992, the number of waivers granted by such agencies on behalf of exchange visitors has increased dramatically. The U.S. Information Agency estimates that at least 95 percent of the waiver applications were filed on behalf of foreign physicians (Ohlhausen W: personal communication). In 1992, the agency approved 486 waiver applications and disapproved none. The agency approved 666 waivers and disapproved 3 in 1993, approved 788 and disapproved 15 in 1994, and approved 1580 and disapproved 17 in 1995. Among the federal agencies that filed waiver applications in 1995, the Department of Agriculture submitted the largest number (651). Virtually all these applications were filed on behalf of rural communities and hospitals trying to attract physicians or lawyers representing doctors from other countries. In 1991, immigration law was liberalized to permit graduates of foreign medical schools who intend to practice in the United States to obtain H-1B visas, which were previously available only for teaching or research. In 1995, the Immigration and Naturalization Service considered eliminating the practice option but backed off under pressure, citing the concern that some communities might otherwise not be able to attract physicians.11 The Department of Health and Human Services recently tried to persuade other federal agencies that a standardized process and set of criteria should be used when seeking waivers. Standardized procedures might reduce the number of waivers, but the outcome is uncertain. The political adversaries in the battle are divided along geographic lines more than along party lines. Almost half of all graduates of foreign medical schools participating in U.S. residency programs are in four states: New York, Illinois, Pennsylvania, and New Jersey (Table 3 not shown). The two most influential private organizations favoring limits on the number of residency positions filled by graduates of foreign medical schools are the American Medical Association and the Association of American Medical Colleges. The memberships of both are divided on this issue. Consequently, neither organization lobbies Congress aggressively on behalf of its position. The testimony of Cohen, president of the Association of American Medical Colleges, certainly reflects unequivocal support for reducing the number of residents who are graduates of foreign medical schools. But most of the organization's New York members oppose the policy, and more important, the state's two senators both serve on the Finance Committee, which has jurisdiction over the matter. In short, as a key House staff member said in an interview, "New York has what is tantamount to veto power on this issue, because both of its senators serve on the Finance Committee." The American Medical Association counts among its 194,000 physician members (including residents) a total of 31,000 graduates of foreign medical schools, some of whom are very active in the association's affairs. On Capitol Hill, the association devotes most of its lobbying to other economic issues. Ways and Means Subcommittee Hearing The political complexity of the debate over graduates of foreign medical schools was apparent at the April 16 hearing convened by the House Ways and Means Subcommittee on Health, which has jurisdiction over Medicare but rarely addresses issues involving the overall supply of physicians. The subcommittee heard from Richard D. Lamm, chairman of the Pew Health Professions Commission, and Dr. Donald E. Detmer, cochairman of the Institute of Medicine's Committee on the U.S. Physician Supply. The Pew commission recently recommended substantially reducing the size of U.S. medical school classes (by 20 to 25 percent) by the year 2005 and the number of residencies (to 110 percent of the number of U.S. graduates), as well as tightening the visa-application process for graduates of foreign medical schools.12 The Institute of Medicine committee recommended that immediate steps be taken to reduce the number of physicians in training, without diminishing the provision of health care to underserved populations.13 Virtually every committee member present at the hearing, from the most conservative Republican to the most liberal Democrat, was either critical of the proposal to curtail the numbers of graduates of foreign medical schools or reluctant to move toward this goal quickly. Representative Bill Thomas (R-Calif.), the subcommittee's chairman, asserted only that the federal government had created the problem, because Medicare pays teaching hospitals for graduate medical education on a per-resident basis, which encourages the hospitals to "make money" by creating more residency positions. Republican Nancy Johnson of Connecticut, who eight months earlier had proposed a strict curtailment of federally funded residency positions for graduates of foreign medical schools, said she was now less sanguine about whether the government should intervene. Struck by the acceleration of hospital mergers and residency-program consolidations, Johnson said, "I wonder whether this is a problem that we can leave to the market." Representative Pete Stark of California, a liberal Democrat who chaired the subcommittee when his party held the majority, underscored the disconnection between an oversupply of physicians and the millions of Americans [who] are poorly served. Rural communities and inner-city communities go begging for doctors, and minorities are underrepresented in the nation's medical schools. I hope that Congress will not just deal with problems of physician oversupply, but will also address problems of maldistribution and lack of access for so many of our fellow citizens. Several Republican committee members pointed to the contributions made by foreign-born physicians in their own states. Representative Jon Christensen of Nebraska, a self-described Reagan Republican bent on reducing the size of the federal government, reducing taxes, and outlawing abortion, told of a Turkish oncologist who had treated his father in a hospital in Grand Island, Nebraska. "He extended my father's life, and I will be forever grateful to him for that." Another Republican, Amo Houghton of New York, who is a former chief executive officer of Corning Glass Works, said his hometown of 12,500 residents had come to depend on graduates of foreign medical schools for health care, because the town could not attract graduates of American medical schools. "I am loath to snuff out that flow of medical talent." Although such anecdotes certainly influence the thinking of legislators, it is well to remember that once they have completed their residency training, most graduates of foreign medical schools set up office-based practices in densely populated urban and suburban areas and pursue medical subspecialties with the same zest as their U.S. counterparts.1 New York's Reliance on Graduates of Foreign Medical Schools Maintaining Medicare funds for residency training is particularly important to teaching hospitals in New York State, because its Republican governor, George E. Pataki, has proposed a sharp reduction (from $1.8 billion to $325 million) in annual state support of graduate medical education. In addition, an advisory panel convened by New York Mayor Rudolph W. Giuliani recommended in May that the city reform the way it pays for medical care for the indigent ? by subsidizing health insurance premiums for the uninsured rather than subsidizing hospitals that treat the poor.14 The Pataki administration has proposed that New York deregulate its hospital-reimbursement system, which now requires all insurers to pay similar amounts for care and also to support graduate medical education. The new proposal is based on the belief that teaching hospitals will be able to negotiate with managed-care plans to receive adjustments for graduate medical education. One state official conceded in an interview that there is no certainty that teaching hospitals will be successful in these negotiations, but he defended the proposed policy by pointing out, "Massachusetts and New Jersey deregulated their all-payer hospital-reimbursement systems, and there is little evidence to date that teaching hospitals have suffered financially as a result." Over the years, New York City's hospitals have been unified in their opposition to changes in federal and state policies that would reduce the number of trainees or payments for graduate medical education. Recently, however, Dr. David B. Skinner, president of New York Hospital, an affiliate of Cornell University Medical School, broke ranks. In a letter prepared for his board that was distributed to hospital executives throughout the city, Skinner said: In the regulatory climate of New York, funding for graduate medical education has been a surrogate for payment to hospitals for other purposes. Approximately $190,000 per resident per year [from all sources] is put into hospital rates [for all payers, as an explicit form of support for graduate medical education], which is significantly more than the direct cost of residency programs. This has encouraged many hospitals without adequately developed teaching programs to establish residencies. As a result these programs are not of great quality and are attractive only to international graduates seeking to practice in the United States. Only one-third of GME (graduate medical education) funding goes to academic health centers committed to top quality education. While the magnitude of the Pataki budget proposal is large, it is a necessary step to addressing the proper sizing of graduate medical education in New York. Seeking Substitute Providers How many hospitals actually depend on residents who are graduates of foreign medical schools to provide care to the poor is uncertain; one recent estimate15 placed the number at 77. If residency positions for such graduates are curtailed, the most frequently recommended option is to expand the National Health Service Corps. The Clinton administration's proposed health care reform called for a fivefold expansion of the corps to provide personnel for medically underserved areas. Established by Congress in 1970 because of concern about a shortage of physicians in underserved areas, the National Health Service Corps has always been subject to the vicissitudes of politics and was even threatened with elimination during the Reagan administration. The corps has a budget of $115.7 million for fiscal year 1996. Mullan recently argued that if the corps is expanded, hospitals dependent on graduates of foreign medical schools can be staffed with fully trained American physicians, financially strapped young doctors can pay off their debts while providing service, and the United States can curtail its dependence on graduates of foreign medical schools to care for the poor.16 Conclusions America's reliance on graduates of foreign medical schools represents a quandary for Congress, particularly the Republican members, who have misgivings about government intervention and believe strongly in private markets. But it is, after all, public policy ? in the form of Medicare's open-ended support for residents ? that exerts the greatest influence on teaching hospitals to create more training positions and fill them with graduates of foreign medical schools. Medicare's impact is becoming even greater as managed-care plans, which are transforming health insurance, resist contributing to the cost of graduate medical education. Politicians are not enthusiastic about addressing the overall question of the supply of physicians, including the number of residents. Thus, it seems unlikely that Congress will soon curtail the number of graduates of foreign medical schools entering residency training or practice. That day may arrive, but not in this election year. Moreover, such a measure is likely to be part of an omnibus budget bill that pares overall Medicare spending, including open-ended support for residency training, but whether it will address the problem of people who lack health insurance is an open question.17 As Congress and the Clinton administration move hesitantly, the medical profession seems more prepared to grapple with work-force issues, particularly those involving the looming surplus of doctors, the growth of managed care and its stricter criteria for the use of practitioners, and low-quality training programs. Paradoxically, while U.S. residency programs accommodate an increasing number of graduates of foreign medical schools, record numbers of American students applying to domestic medical schools are denied admission because of the concern that too many doctors are already being trained. References 1. Mullan F, Politzer RM, Davis CH. Medical migration and the physician workforce: international medical graduates and American medicine. JAMA 1995;273:1521-1527. 2. Lee PR. Presentation at Palo Alto Medical Foundation Annual Conference, San Francisco, March 23, 1996. 3. Iglehart JK. Reducing residency opportunities for graduates of foreign medical schools. N Engl J Med 1985;313:831-836. 4. Annual report to Congress, 1994. Washington, D.C.: Physician Payment Review Commission, 1994. 5. Council on Graduate Medical Education. Fourth report: recommendations to improve access to health care through physician work force reform. Rockville, Md.: Department of Health and Human Services, 1994. 6. Shine KI. Freeze the number of Medicare-subsidized graduate medical education positions. JAMA 1995;273:1057-1058. 7. Cohen JJ. The importance of the Medicare program in supporting academic medicine. Testimony delivered on behalf of the Association of American Medical Colleges before the Senate Finance Committee, Washington, D.C., July 26, 1995. 8. Iglehart JK. The struggle to reform Medicare. N Engl J Med 1996;334:1071-1075. 9. Glanz J. Proposals that would limit visas strike fear at universities. Science 1996;272:190-191. 10. Levine FJ. Keep borders open for U.S. science. Science 1996;271:1649-1649. 11. Mitka M. IMGs repel federal effort to close immigration door. American Medical News. March 6, 1996:6. 12. The Third Report of the Pew Health Professions Commission. Critical challenges: revitalizing the health professions for the twenty-first century. San Francisco: Center for the Health Professions, University of California, 1995. 13. Lohr KN, Vanselow NA, Detmer DE, eds. The nation's physician workforce: options for balancing supply and requirements. Washington, D.C.: National Academy Press, 1996. 14. Fein EB. Panel urges shift in how New York pays health bills. New York Times. May 2, 1996:A1, B4. 15. Whitcomb ME, Miller RS. Participation of international medical graduates in graduate medical education and hospital care for the poor. JAMA 1995;274:696-699. 16. Mullan F. Powerful hands: making the most of graduate medical education. Health Aff (Millwood) 1996;15:250-253. 17. Schroeder SA. The medically uninsured -- will they always be with us? N Engl J Med 1996;334:1130-1133. |
I M G I, Inc. [ Home | About Us | Advertisers ]
|