Can Immigration Ease a Growing Psychiatrist Shortage?

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North Platte, Neb.—population 24,733—has two psychiatrists. Both are immigrants.

By Laura D. Francis

North Platte, Neb.—population 24,733—has two psychiatrists. Both are immigrants.

Without them, the city, “and probably the surrounding 100 miles,” would have “no access at all” to psychiatric services, Dr. Howard Liu, director of the Behavioral Health Education Center of Nebraska, told Bloomberg Law Oct. 18. “I really do think” that immigrants “are a lifeline for many smaller communities,” said Liu, a child psychiatrist at the University of Nebraska Medical Center.

That lifeline may be especially critical with the growing U.S. psychiatrist shortage.

“The number of psychiatrists is effectively declining” in proportion to the population, Liu said. The drop will mean much longer wait times, and an increase in areas of the country that have “no access” to a psychiatrist.

That’s already resulted in clinics and mental health practices “rationing” services to those who need them the most, using nurses or case managers for intake, extending prescriptions for longer periods of time, a reduction in appointment length, and “inadequate” diagnosis and prescriptions as well as an overuse of antipsychotic drugs, according to a report co-authored by Liu.

Lack of Access

More than 60 percent of U.S. counties, including 80 percent of rural counties, don’t have a single psychiatrist, according to a report from New American Economy provided exclusively to Bloomberg Law. In those rural counties, 590 psychiatrists serve more than 27 million people.

NAE is a coalition of mayors and business leaders who support an immigration overhaul. It’s co-chaired by former New York Mayor Michael Bloomberg, the chief executive officer of Bloomberg Law affiliate Bloomberg LP.

That demand only is increasing, the report said. Using data from Burning Glass Technologies, which analyzes online job postings, NAE said job postings for psychiatrists grew from 10,800 in 2012 to 34,312 in 2016.

A third of all psychiatrists in the U.S. are immigrants, the report said.

The current shortage is projected to get even worse as psychiatrists retire. “The provider workforce in general has been aging,” Liu said. In Nebraska alone, more than 50 percent of psychiatrists, psychiatric nurses, and psychologists are over 50, he said.

Foreign Grads ‘Get the Leftovers’

Immigrants get the residencies that U.S.-born citizens don’t want, immigration attorney Jan Pederson of Maggio Kattar in Washington, D.C., told Bloomberg Law Oct. 13. Psychiatry “is one of the lowest-paid specialties,” and so “it’s hard to get an American,” she said. “Foreign medical graduates get the leftovers.”

Psychiatrists get lower reimbursements from insurance companies than other specialties, and Medicare and Medicaid rates “have not been particularly high,” Liu said.

On the other hand, “it’s been well-proven that many of these international medical graduates do practice in more underserved communities,” he said.

Even if immigrants are more than willing to practice psychiatry, and in more underserved areas, it’s not easy for a foreign national who was educated abroad to become a physician in the U.S.

“You’re required to take five or six exams to be credentialed to take residency training in the United States,” Pederson said, and then getting into a residency program isn’t easy.

Of the 1,495 psychiatry residency slots available in 2017, only 137 (9.2 percent) went to foreign nationals who attended medical school abroad, according to figures from the National Resident Matching Program. That represents a 50 percent decline in the percentage of residency slots held by foreign-trained immigrants since 2008, when they held 18.8 percent of psychiatry residencies, according to a separate report.

Visa Uncertainty

“It’s going to become more difficult” as hospitals become more uncertain whether they’ll get the visas needed to bring foreign nationals into residency programs, said Pederson, who has served as president of the Washington, D.C., chapter of the American Immigration Lawyers Association and on its national Board of Governors.

Earlier this year, a group of 38 Pakistani doctors were denied J-1 exchange visitor visas for their residencies after coming to the U.S. on B-1 temporary business visitor visas to take their exams, Pederson said. They also participated in medical observerships, during which they shadowed physicians and got to undertake the networking needed to get accepted into a residency program, she said.

Pederson said the J-1 visas were denied on the grounds that it didn’t appear that the doctors intended to return to their home countries after their visas expired—a requirement of the J-1 program. Eventually, 34 of the 38 were able to get their visas and pursue their residencies, but not until after several had applied and paid fees several times over, she said.

A representative for the State Department told Bloomberg Law Oct. 18 that the law prevents the agency from discussing the particulars of visa information.

Need to Get Waiver

More and more hospitals are using the J-1 visa as the vehicle for medical residencies, immigration attorney Elissa Taub of Siskind Susser in Memphis, Tenn., told Bloomberg Law Oct. 13. The alternative is the H-1B specialty occupation visa, but it imposes more financial burdens on the employer, she said.

Unlike J-1 visas, H-1B visas allow for “dual intent": coming to the U.S. on a temporary visa but also intending to pursue permanent residence, Taub said.

Physicians pursuing their residencies on a J-1 visa can get a waiver of the requirement that they go back to their home countries for at least two years before returning. And a handful of waiver programs funnel physicians into high-need areas.

The Conrad State 30 program, for instance, allows states to seek up to 30 waivers per year if the physician agrees to practice for at least three years in a medically underserved area. “It would be great if there were more Conrad slots,” but psychiatrists already get some priority under the existing program, said Taub, who has served on AILA’s Healthcare Professionals Committee.

To get a waiver slot, a state must show that the physician would be practicing in a “health professional shortage area,” “medically underserved area,” or “medically underserved population,” as designated by the Health and Human Services Department, Taub said. But there’s also a “mental health professional shortage area” designation, she said.

‘Pretty Good Feeling’

“I have a pretty good feeling” with respect to psychiatrist waiver applications, because states clamber for immigrant psychiatrists as a result of the shortage, Taub said. In fact, some states only allow psychiatrists to be placed in MHPSAs, not HPSAs, MUAs, or MUPs, she said.

Other waiver programs, operated by the federal government, allow for unlimited waivers per year, Pederson said. But those programs have other restrictions that make them difficult to use, she said.

The current immigration system “is not meeting the health needs of our population,” the NAE said in its report. “The development or expansion of visa programs” that would ease the ability for “highly in-demand specialists like psychiatrists to practice in the United States would be a step in the right direction,” the organization said. “Equally so would be a visa system allowing individual areas, such as states, cities, or towns to sponsor immigrant doctors.”

If immigration declines, the communities that will be hurt the most are those with the greatest need, Liu said. Immigration is a “very important piece” of addressing the psychiatrist shortage, he said.

To contact the reporter on this story: Laura D. Francis in Washington at lfrancis@bna.com

To contact the editor responsible for this story: Terence Hyland at thyland@bna.com

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