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April 16, 2014

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At first blush, a tough J-1 board

Council formed in wake of criticism doesn’t roll over on first application

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Nevada’s latest effort to reform a program that brings foreign physicians to the state is off to a deliberate and disciplined start.

For the first time ever, health care experts debated in public the merits of hiring arrangements for the physicians.

At issue is how to ensure that foreign doctors in the J-1 visa waiver program devote the required amount of time to medically needy patients — without being exploited by employers who, a Sun investigation found last fall, have overworked and underpaid some and assigned them to more lucrative tasks.

The complaints are of no small consequence in Nevada, where about 250 foreign doctors have worked in the J-1 visa waiver program over the past 10 years.

In the wake of the Sun investigation, the state created a review board to examine employers’ applications to hire foreign doctors and to monitor compliance with the program.

And as the Primary Care Advisory Council’s inaugural meeting last week showed, employers who previously had the run of the roost learned they won’t so easily get their way in how they hire and assign doctors.

Witness what happened Friday: A physician and a billing manager who work for Dr. Dhiresh Joshi, a prospective J-1 employer, grew agitated when members of the committee probed his application to hire a Jamaican infectious disease specialist.

Joshi’s application raised eyebrows for several reasons. Traditionally, employers hire primary care doctors to work in clinics in underserved areas. But Joshi wanted an infectious disease specialist to work primarily in a North Las Vegas clinic for an unspecified number of hours. He said she also would be assigned to rounds in local hospitals in medically underserved areas.

Joshi’s application did not clearly state the volume of patient visits that could be expected in the underserved North Las Vegas clinic — which could call into question whether the J-1 doctor would work there or be diverted to hospitals.

Such questions go to the heart of abuses within the J-1 program, the Sun found.

The foreign doctors who complete their medical residencies in the United States are allowed to remain if they commit to working at least 40 hours a week in medically underserved communities. But several employers who have hired the bulk of foreign doctors in past years were diverting them to affluent communities where they could bring in more money for the boss, frequently at the expense of caring for those in need of medical attention.

In other cases, the foreign doctors were worked more than 80 hours a week, the point where exhaustion makes things risky for patients, and others were not paid, or their contracts were changed against their will.

The foreign physicians were reluctant to complain because their employers had sponsored their visas. Oversight by state health officials had grown almost nonexistent.

Concerns about program abuses brought calls for investigations from Senate Majority Leader Harry Reid and the American Medical Association, and multiple changes by the Nevada State Health Division, where J-1 oversight was assigned to a different manager and a complaint system was created to allow doctors to voice their concerns.

The creation of the advisory council is one of the most important reforms because the board adheres to open meeting law, making documents public and allowing time for public comment.

In the initial case heard Friday, advisory council member Caroline Ford, an assistant dean at the University of Nevada School of Medicine and director of the school’s Center for Education and Health Services Outreach, said it was hard to tell how many patients would be seen at the clinic where Joshi’s new hire would practice. She wanted to wait 30 days to approve the application so the council could get more information.

Council member Larry Matheis, executive director of the Nevada State Medical Association, said Joshi’s application was “confusing about some fundamental questions” and did “not give confidence” that the program’s guidelines will be followed closely.

“These are the sort of gray-area issues that led to the Las Vegas Sun series,” Matheis said.

A third council member, Dr. Carl Heard, interim chief executive and medical director of the nonprofit Nevada Health Centers, agreed with Matheis’ assessment of the application. But he emphasized that the process of hiring a J-1 doctor takes many months of jumping through bureaucratic hoops and if the process is set back even 30 days it could cost Nevada a qualified physician.

“Access to care is what we’re here to do,” Heard said.

State officials wrote in their review of Joshi’s application that there are no infectious disease specialists in North Las Vegas, though there are 18 at University Medical Center, one of the hospitals where the potential J-1 doctor would work. The Jamaican doctor also speaks Spanish, which would benefit the North Las Vegas community, the state officials noted.

Dr. Fadi El-Salibi, who currently works with Joshi and was a J-1 doctor under him in North Las Vegas, said not having an infectious disease specialist in North Las Vegas makes it difficult for patients to receive follow-up care when they’re discharged from the hospital.

In the end, the meeting showed that the program’s success will still depend, in large part, on the ongoing monitoring provided by the Nevada State Health Division. Joshi’s application was recommended for approval Friday on the condition that he submits information within 15 days so the state can monitor his compliance. Officials in the health division have final authority.

Dr. Amir Qureshi, chairman of the council, noted that the new panel operates in a much different manner from that of the previous J-1 advisory committee.

“The open process makes it very transparent,” he said. “Everyone gets an opportunity to say what they want, including the public.”

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