HHS endorses the philosophy that exchange visitors return home after completing their training to make their new knowledge and skills available to their home countries. As a result, HHS does not support waivers for physicians to remain in the United States to practice in underserved areas. The other major primary care specialties were pediatrics and family practice. By 1995, there were nearly 30 federal agencies and states processing requests for waivers for physicians with J-1 visas. The four federal agencies have no formal process for coordinating their waiver requests and they have overlapping jurisdictions. Monitoring Varies Among Federal Agencies and States

Agency controls to help ensure that physicians comply with waiver agreements vary among the federal agencies and states. The new regulations, if finalized, and the 1996 amendments could address many of the coordination and compliance problems, but not all of them. Many health care facilities and states cite examples of the utility of these waivers in providing a qualified physician for an underserved area. To look at coordination of physician placements, we cross-tabulated the agency data on waiver requests received by the agencies between 1994 and 1995 by state and selected those physicians whose waiver requests were sent to USIA between 1994 and 1995. Compliance

We identified instances where physicians did not comply with the terms of the waiver through (1) discussions with the ARC Inspector General and a review of reports from that office, (2) our survey of facilities where requesting agencies believed that the physicians were practicing, (3) site visits to facilities where the physicians were supposed to be practicing, and (4) discussions with USIA and other agency officials. (check all that apply)
15% We rely on other federal or state 38% We act in response to reports from other federal or state agencies 32% other (please specify)
97% Whether the practice location is in a health professional shortage area (HPSA) please continue on next page--> 65% Whether the practice location is in a medically underserved area/population (MUA/MUP) 29% Whether other state J-1 visa waiver physicians are practicing in the area 24% Whether other J-1 visa waiver physicians who received waivers through U.S. government agencies are practicing in the area 27% Whether physicians under National Health Service Corps (NHSC) obligations are practicing in the area 85% Whether the facility has tried recruiting in the past without success 0% None of the above factors J-1 VISA WAIVERS REQUESTED BY U.S. GOVERNMENT AGENCIES 9. 8. Waiver Requests for Physicians With J-1 Visas, by States and Federal Agency, 1990-95

Results of GAO Survey of Health Care Facilities Regarding Waivers for Physicians With J-1 Visas, 1994-95 Requests

This appendix contains the responses to questions we asked facilities that requested waivers of the J-1 visa foreign residence requirement for physicians. Table VI.3: Practice Specialties of Waiver Physicians Practicing on January 1, 1996

DOT  (n=2)
ARC  (n=38)
HUD  (n=29)
USDA  (n=81)

Physician Need and Number of Waiver and National Health Service Corps Physicians, by State, 1995

This appendix contains information for each state showing (1) the identified physician need in the state (2) the number of physicians with waivers granted or in process, and (3) the number of physicians who received NHSC scholarships or federal loan repayment who were practicing in the state. Washington, D.C.: U.S. Department of Health and Human Services, 1988.
Why GAO Did This Study

GAO reviewed the extent to which state and federal agencies used waivers to meet physician shortages in medically underserved areas, focusing on: (1) how many foreign physicians with J-1 visas receive waivers, where they practice, and their medical specialties; (2) whether federal agencies and states effectively coordinate policies and procedures for granting these waivers; and (3) the extent to which foreign physicians who receive waivers comply with waiver requirements to practice in underserved areas.

What GAO Found

GAO found that: (1) the number of waivers for physicians with J-1 visas to work in underserved areas has risen from 70 in 1990 to over 1,300 in 1995; (2) requesting waivers for physicians with J-1 visas has become a major means of providing physicians for underserved areas; (3) in 1994 and 1995, the number of waivers processed for these physicians equaled about one-third of the total identified need for physicians in the country; (4) almost all of these waiver physicians have primary care medical specialties and they are practicing in 49 states and the District of Columbia; (5) nearly 30 federal and state agencies were processing waiver requests for physicians from hospitals, health centers, and other health care facilities by 1995; (6) among them, no agency has clear responsibility for ensuring that placement efforts are coordinated; (7) although the federal agencies are now working together informally, they still have differing policies, overlapping jurisdictions, and varying communication with the states; (8) the Department of Health and Human Services (HHS) believes that the physicians should return home after completing their training to meet the intent of the exchange visitor program, and the other agencies view the waiver provision as a means to secure physicians to meet the health care needs of their constituents; (9) while more than 9 of every 10 physicians whose waivers were processed between 1994 and 1995 were practicing at their locations in January 1996, controls are somewhat weak for ensuring that physicians continue to meet the terms of their agreements; (10) even when the physicians and facilities follow the agencies' rules, the rules do not restrict physicians from working with those segments of the population that already are adequately served; and (11) proposed regulations published by the United States Information Agency and developed in working with the informal interagency group, coupled with recent amendments to the Immigration and Nationality Act would address many of the coordination and compliance problems, but not all of them.