Mark G. Tozzio, FACHE, senior vice president, Business Development and Marketing, CHI - St. John's Regional Medical Center, Joplin, Missouri

ORGANIZATIONAL INFORMATION
The organization is a full-service tertiary-level rural healthcare system with 392 inpatient beds and comprehensive outpatient diagnostic and treatment services; its hospital system employs approximately 2,200 clinical and support people. The system's base is located in a small metropolitan community with a 19-county rural service area covering four states, which constitutes a vast referral region with a population base of 750,000. It is a not-for-profit organization that became a member of a national health system in 1996; it is the market leader of cardiovascular, oncologic, orthopedic, and trauma services in the region, with approximately 16,500 patient admissions and 140,000 outpatient visits annually; and its net revenue totaled $223 million in fiscal year 2003.
The system's patient reimbursement mix is heavily skewed toward government payers because of an older rural population base: 14 percent of the region's residents are over 65 years of age. About 22 percent of the system's patients reside in the targeted service area (southeast Kansas). Overall, Medicare patients generated 65 percent of the system's total net revenue.
Because of the acute shortage of primary care physicians in the area, for the past ten years the hospital system has served the rural population by operating three rural health clinics staffed by primary care physicians. In 1999, the system agreed to take over the operation and management of a small critical access hospital with 25 beds located in a federally designated health manpower shortage area served by one of the rural health clinics.

BRIEF STATEMENT OF THE PROBLEM
The region of southeast Kansas has a rural population supported predominantly by an agricultural and light industry economy. The majority of households have an income below the state average, and a large portion of the population is over 65 years of age. Consequently, the major health insurance providers are Medicare and Medicaid. These facts make it particularly difficult to attract and retain younger physicians and health providers, who tend to favor larger metropolitan areas with a lower dependence on government reimbursement and greater commercial base.
As is the case for the majority of rural communities across the United States, recruitment of primary care physicians is a long and arduous process. U.S.-born primary care physicians typically are less attracted to practice opportunities in small rural communities, although the quality of life in these areas can be a selling point. Most physicians are trained in larger metropolitan medical centers and have become used to having the latest technology, sophisticated hospitals, endless subspecialists, group practice coverage arrangements, and a generous employment and benefits package. These attributes are seldom available in rural communities like the ones in the region.
Often, the only alternative is to recruit foreign-born physicians, also referred to as "J-1 physicians," who commit to work in designated health manpower shortage areas in exchange for authorization to remain in the United States after completing their medical training. These foreign-born physicians receive approval from the U.S. Department of State and Immigration and Naturalization Service (INS) to work in health shortage areas for a minimum of three years. Without the J-1 Visa Waiver, foreign-born physicians must return to their homeland for at least two years before being able to live and work in the United States.
In Kansas, because of the connection between small rural communities and agriculture and farming industries, the only government agency that acted as a sponsor of J-1s was the U.S. Department of Agriculture (USDA), which made recommendations to INS to grant the J-1 Visa Waiver to foreign-born physicians willing to serve in rural communities. During the eight years following the federal congressional enactment of the J-1 program in the United States, the USDA played a key role in bringing 98 foreign-born physicians to rural Kansas and an additional 3,000 physicians to other shortage communities across the country. On February 27, 2002, the USDA abruptly discontinued their sponsorship of the J-1 Visa Waiver program across the country, without any advance notice and in midstream of processing more than 100 applications for rural physician candidates. This action sent shockwaves throughout hundreds of rural communities that were depending on recruiting foreign-born physicians with the assistance of the USDA, including the healthcare system's rural health clinic, which would be left with minimal primary care physician coverage. The existence of the system's critical access hospital was threatened as well-no physician, no hospital.
As the executive responsible for physician recruitment activities for our healthcare system, I worked diligently with local, state, and federal officials to successfully address this crisis. For several months, I helped create a new program in the state's Department of Health and Environment to replace the sponsorship eliminated by the USDA. Without personal involvement and action in the government and political process relating to the J-1 Visa Waiver program concerning Kansas, the health needs of the rural population would suffer a tremendous loss of valuable primary care providers.

DESCRIPTION OF THE PROBLEM
Foreign-born Medical Graduates' Essential Role in Rural Healthcare
Policymakers have long recognized the maldistribution of primary care physicians across the country. The guidelines published by federal health agencies encourage the availability of primary care physicians in rural communities in an attempt to achieve a ratio of one physician for every 3,000 persons and a maximum travel distance of 25 to 30 miles to essential healthcare services. Unfortunately, physicians have concentrated in larger metropolitan regions, and not enough U.S.-born physicians choose to locate their practices in many rural communities. To attempt to address the manpower shortage problem in rural America, politicians and government agencies have worked together to create various programs to incentivize physicians to move to rural communities, including the National Health Service Corps, student loan forgiveness, and cost-based reimbursement for primary care clinics.
In communities that have documented shortages of primary care physicians and can demonstrate that U.S.-born physicians are not available to staff primary care clinics, the Department of State/INS is authorized to grant permission for foreign-born physicians to remain in the United States to serve the primary care needs of the population following their U.S. medical training. The J-1 Visa Waiver for foreign-born physicians is one example of a program that ensures care for designated manpower shortage areas.
The J-1 visa sponsorship program operates under the auspices of Section 220 of the U.S. Immigration and Nationality Act, permitting interested government agencies to act on behalf of foreign medical graduates who are in the United States on J-1 visa status. Under this federal program, the INS grants the applicant a J-1 Visa Waiver based on his or her commitment to serve as a primary care physician in federally designated health professional shortage areas, instead of having to return to his or her homeland for a minimum of two years following completion of the medical training in the United States.
Since 1994, the USDA has sponsored more than 3,000 primary care physicians to work in medically underserved rural communities when recruiting a U.S.-born physician was not possible. Recent changes to the act (P.L. No. 103-416, 108 Statute 4319-20), known as the Conrad State 20 Rule, allow state public health agencies to also request and sponsor up to 20 waivers per year as long as the physician serves in federally designated health professional shortage areas. As of January 2002, 44 states had implemented the Conrad State 20 Rule; however, Kansas was one of six that elected not to adopt the program and relied solely on the USDA for sponsorship of foreign-born physicians in rural communities in the state.

Strategy for Recruiting Primary Care Physicians
For several years, our healthcare system's critical access hospital has struggled to recruit and retain primary care physicians to staff the emergency room and provide routine medical care to patients. In 1999, the system assumed the operation and management of the hospital to enhance the facility's chances of survival; the system also operates a local rural clinic, which is staffed by two primary care physicians and a physician's assistant. Overall, the county continues to have a shortage of three primary care physicians.
In late 1999, our system recruited a foreign-born cardiologist trained at a prestigious U.S. university who is a board-certified internal medicine specialist. This physician agreed to be employed for three years at our rural health clinic and to serve as a primary care physician in exchange for the J-1 Visa Waiver sponsored by the USDA. He intended to remain in the region and practice full-time cardiology at our tertiary healthcare facility, some 35 miles from the rural community, at the end of his primary care obligation under the J-1 Visa Waiver program. This prompted us to look for a replacement physician toward the end of his commitment period.
We were fortunate to recruit another foreign-born physician to replace the existing practitioner; he planned to start in November 2002, as soon as the USDA agreed to sponsor him and recommend that a J-1 Visa Waiver be granted by the Department of State/INS. The J-1 Visa Waiver process is very complex, costly, and lengthy, and it can take up to 12 months to complete. Timing is critical to ensure that the physician is available when the vacancy arises.
The local community and medical providers were excited about the prospect of recruiting a replacement physician. In the fall of 2001, all of the necessary arrangements for the J-1 Visa Waiver were progressing as planned with the USDA. However, a series of tragic acts were carried out by foreign terrorists in New York City; Washington, DC; and rural Pennsylvania on September 11 that year; thousands of people lost their lives. This grave situation caused Congress and all government agencies to reevaluate policies and procedures dealing with foreigners in the United States, including the process of granting visas to foreign-born physicians.

USDA Terminates the J-1 Visa Waiver Program
On February 27, 2002, the USDA issued an abrupt announcement that it intended to terminate its participation in the J-1 Visa Waiver program nationwide; no further action would be taken on any applications that were currently in process with the agency. The USDA officials issued a news release stating the following:
As a result of its program review, USDA has come to the conclusion that while the program served valid and important purposes, the benefits of USDA's involvement are clearly outweighed by potential problems and risks. Therefore, effective February 27, 2002, USDA will no longer act as an interested government agency on behalf of those desiring recommendation of a J-1 Visa Waiver. Pending waiver requests will be returned to the sender.

This news created a physician crisis for our rural health clinic, which was depending on the recruitment of the new foreign-born physician to relocate in fall 2002. Without any other new prospective primary care physicians to staff the clinic and to care for patients in the critical access hospital, the future viability of the local hospital was in jeopardy.
I immediately began working with officials from the Office of Rural Health in the state's Department of Health and Environment to develop a strategy to either convince the USDA to finish processing the applications that were pending at the time of the February 27 announcement or appeal to the governor to implement the Conrad State 20 Rule for the state and become the sponsor for our foreign-born physician to practice in the area.

Developing Public and Political Support for the J-1 Visa Waiver Program
After talking extensively with the director of the program, it was evident by mid-March 2002 that the USDA would not reconsider its position on terminating the J-1 Visa Waiver sponsorship, even for the 86 individuals who were in the middle of the process. I began a letter-writing campaign to state and federal legislative representatives explaining the critical situation and asking for help in dealing with the crisis caused by the USDA's abrupt termination. The quick response by congressmen from Kansas was very encouraging, and the state's hospital association also joined in the campaign process and enlisted statewide support. On March 14, 2002, U.S. Rep. Jerry Moran wrote to the deputy secretary of the USDA, the assistant secretary of the Bureau of Consular Affairs, the director of Homeland Security, and the commissioner of the INS urging a speedy resolution to the J-1 Visa Waiver sponsorship dilemma that affected so many rural communities. Congressman Moran noted that, "The USDA's decision to discontinue its participation in the program without formal prior notice and to return pending J-1 Visa Waivers applications to applicants is contrary to the fundamental mission of the USDA."
The legislative staff members for both of our state's congressmen cited our rural health clinic as an example of the importance of the J-1 Visa Waiver program and referred the news media to contact me to discuss the physician recruitment circumstance. A front-page story ran in Kansas City Star on March 25. The story focused on the local physician serving his J-1 Visa Waiver commitment in the small rural community and the efforts of community leaders to maintain adequate medical services. This news story helped draw the attention of the governor and state legislators, who began carefully evaluating options to step in where the USDA had left off on the recruitment of foreign-born physicians. The story also drew national attention to our region and the J-1 crisis.
In early April, I wrote a compelling letter to the secretary of the state's Department of Health and Environment, urging him to intervene on behalf of foreign-born physicians caught in the USDA termination saga. This letter was hand delivered to the governor's office by the secretary.
The administrator of the critical access hospital and I also contacted a state representative from the region to enlist his support in convincing the governor to implement the Conrad State 20 Rule. He was extremely interested and instrumental in meeting with the governor's attorney assigned to track the J-1 issue for four Kansas-bound physicians seeking visa waivers through sponsorship by the USDA. It came to light that the governor had received conflicting information about the process for obtaining security background checks on foreign-born physicians and potential risks for states using the Conrad State 20 Rule.
I collaborated with several experts and provided a white paper addressing specific issues and concerns uncovered by the Columbus Representative during discussions with the governor's staff. These efforts resulted in the limited implementation of the Conrad State 20 Rule by the governor on April 12, 2002. The governor's staff made it clear that this action covered only the four foreign-born physicians affected by the USDA action and that the next governor would have to make the final decision on a permanent program in Kansas.
I continued to work closely with legislative aids for congressmen Jerry Moran and Sam Brownback to seek the following actions:

• Convince the USDA to reinstate their sponsorship of J-1 Visa Waiver recommendations for all 86 foreign-born physicians being processed at the time of the termination announcement
• Enact legislation to reauthorize and expand the authority of states, through the Conrad State 20 Rule J-1 Visa Waiver program, to act as sponsors of foreign-born physicians in their jurisdictions

On April 16, Congressman Moran announced, "The USDA will serve as a temporary interested government agency, in order to process the pending applications." The head of the USDA stated in his letter to the Congressman that the USDA would process the 86 pending waiver requests with the help of security clearances from the Department of Justice and Department of State and that the United States Department of Health and Human Services would do follow-up monitoring. (The USDA remained adamant that the agency would not continue to participate in the J-1 Visa Waiver program after it finished processing these 86 pending applications.) The regional media reported the event as a major victory affecting health manpower in rural communities across the United States.
All four foreign-born physicians seeking opportunities to work in rural communities in Kansas were sponsored by the state's Department of Health and Environment and granted J-1 Visa Waivers by the U.S. Department of State/INS by the summer of 2002.

State and Federal Legislators Support the J-1 Visa Waiver Program
On April 30, I joined a small group of leaders who met personally with officials from the governor's office and the secretary of the state's Department of Health and Environment to present a proposal for developing specific guidelines to permanently implement the Conrad State 20 Rule. The day after this crucial meeting was held at the capitol, our state legislator filed a resolution in the House of Representatives in favor of the full and immediate implementation of the Conrad State 20 Rule for J-1 physicians in Kansas. The resolution passed in the House with a vote of 120 members in favor and no members against the program!
Meanwhile, the U.S. House Judiciary Committee approved legislation (H.R. 4858) introduced by U.S. Rep. Jerry Moran to reauthorize and expand the Conrad State 20 Rule for foreign-born physicians and boost the number of J-1 Visa Waivers that states can recommend to the U.S. Department of State/INS annually from 20 to 30 (the vote in Congress was 407 to 7 in favor of the legislation). U.S. Sen. Sam Brownback cosponsored a similar bill that also was approved by the Senate.
On August 1, 2002, based on the recommendation of the secretary of the state's Department of Health and Environment and the backing from the state House of Representatives, the governor issued a formal request to the U.S. Department of State, J-1 Waiver Review Division, asking that Kansas participate in the J-1 Visa Waiver Program authorized by Section 212(e) of the Immigration and Nationality Act, as amended.
Furthermore, the secretary of the state's Department of Health and Environment accepted the proposed guidelines suggested by myself and my colleagues and implemented policies and criteria for the J-1 Visa Waiver program, effective September 1, 2002. This program is presently available to communities throughout Kansas to take advantage of quality foreign-born physicians and to help address health manpower shortage needs in future years.

ADMINISTRATIVE DECISIONS
Without a coordinated and proactive strategy to deal with the state crisis caused by USDA's termination of participation in the J-1 Visa Waiver program in late February 2002, rural residents would be at risk of a lack of quality medical services in the future. The implementation of the Conrad State 20 Rule in Kansas was the direct result of excellent teamwork, hard work, and responsible leadership initiatives from concerned healthcare executives, government officials, legislators, physicians, attorneys, and dedicated community leaders.
Careful selection of influential legislators to help navigate the bureaucracy at the federal and state levels and sharing of factual information about the critical nature of foreign-born physicians throughout rural United States resulted in important changes to legislation and policies. Perseverance and an excellent communication network were essential ingredients for successfully implementing the J-1 program in our state as well as expanding the number of J-1 Visa Waivers a state can recommend for approval each year starting in federal fiscal year 2003. Appropriate use of the media was also helpful for moving the process along and gaining attention.
Healthcare executives must be proactive and become responsibly involved in the legislative and governmental processes to have a positive effect on changes in the healthcare delivery system.

RESULTS
This project began on February 27, 2002, with the announcement by USDA officials that they intended to terminate their involvement with the J-1 Visa Waiver program for foreign-born physicians wishing to serve health manpower shortage areas in rural United States. The successful conclusion of the campaign came on August 1, 2002, when the governor agreed to fully implement the Conrad State 20 Rule.
I worked closely with many local, state, and federal legislators and government officials to increase awareness of the serious nature and potential consequences of the USDA's termination of J-1 sponsorship for rural communities across the United States. The USDA's action could have had lasting negative healthcare implications for residents of small rural communities that are experiencing health manpower shortages. However, because the governor was encouraged by leaders to act promptly to implement the Conrad State 20 Rule, the future seems brighter for healthcare providers and residents.
A key focus of the J-1 campaign was to convince the governor and officials at the state's Department of Health and Environment that it was in the state's best interest to implement the Conrad State 20 Rule and not to rely on the USDA or another interested federal government agency to sponsor foreign-born physicians to help address the health manpower shortage throughout the state. My timely communication with several interested parties over a five-month period enhanced the likelihood of favorable actions by the secretary of the state's Department of Health and Environment and the governor.
The collaborative intervention by healthcare leaders, coupled with the affirmative action of local state representatives, as well as the support from influential congressmen, definitely resulted in the implementation of the Conrad State 20 Rule in Kansas over a shorter time frame (relative to governmental action).
The groundwork with the state Department of Health and Environment officials also paved the way for a more favorable policy for managing the state's J-1 Visa Waiver program beyond the four foreign-born physicians addressed by the governor's original action. The United States Congress ultimately passed legislation reauthorizing and expanding the J-1 Rule that allows states to sponsor up to 30 foreign-born physicians each year to help meet the healthcare needs of medically underserved areas.

SOURCE MATERIALS
C., M. 2002. "Doctors Kicked Out." Newsweek (April 1): 8.

Dvorak, J. A. 2002. "Anti-Terrorism Step Backfires on a Kansas Hospital." Kansas City Star (March 25): A-1, A-6.

---. 2002. "Kansas to Help Bring Foreign-born Doctors to Serve in State." Kansas City Star (April 14): B-4.

---. 2002. "Visa Program Back on Track." Kansas City Star (April 20): B-4.

Editor. 2002. "Efforts Avert Shortage of Health Care in City and Waivers Are Victory for Rural Areas." Columbus Daily Advocate (April 17): A-1.

Gatewood, D. 2002. "Kansas State Legislature. Resolution Urging Implementation of the Conrad 20 Rule in Kansas." House Resolution No. 6018.

Owens, D. L. 2002. "Immigration-Looking Through a Security Lens." Kentucky Bar Journal (Bench & Bar), Volume 66; Number 1: 29-36.

Piotrowski, J. 2002. "Ruts in the Rural Field." Modern Healthcare 32 (12): 18.

U.S. Congress. 2002. "Conrad/State 20 Waivers for Foreign Medical Graduates," authorized in Section 212(e) of the Immigration and Nationality Act, as amended in 1996, 8 U.S.C. 1182(e). Washington, DC: U.S. Government Printing Office.

---. 2002. "Waivers of Foreign Country Residence Requirement with Respect to International Medical Graduates," Section 202 P.L. 103-416 Immigration and Nationality Act of 1994. Washington, DC: