Big news! FMG can now receive a medical license and practice independently in TN without completing a US residency.

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Splenda88

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That bill was passed last week

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Lots of hoops for them to jump through but yes - provides a route to US licensure. In practice, probably more applicable to FMGs than IMGs given that you have to have completed an equivalent residency and practiced at least 3 years in another country and been licensed in that country. Even then, they have to do 2 years of practice at a TN hospital with an accredited residency program before they can be granted full licensure.

For a practicing foreign physician who wants to come to the US, it’s a nice option depending on the details the board ultimately sets out. Rather than redoing a whole US residency, you do a couple years at a big hospital with likely some supervision and if your supervisors think you’re solid, then you can get a full TN license.

Nice way to address some of the physician shortage issues through policy.
 
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This is a disaster and is the first step towards something that will be 10000x worse than mid level independent practice
 
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This is a disaster and is the first step towards something that will be 10000x worse than mid level independent practice
Have to disagree. I’d take a fully licensed MD from the UK or Italy or Lebanon who has completed what’s usually a much longer residency than the US and been practicing independently in their home country for 3 years, over a US-trained midlevel any day. Just for further safety, these docs still have to practice under some supervision for 2 years in the US at a teaching hospital and get signed off that they’re safe to practice.

That’s a lot more scrutiny than midlevels where you can do an online NP and shadow for a few months and voila you’re ready!

The teaching hospital provision will also limit the reach of this a bit. Only a few residency programs in the state.

It’s not like they’re handing out licenses to Caribbean grads with no residency training.
 
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Have to disagree. I’d take a fully licensed MD from the UK or Italy or Lebanon who has completed what’s usually a much longer residency than the US and been practicing independently in their home country for 3 years, over a US-trained midlevel any day. Just for further safety, these docs still have to practice under some supervision for 2 years in the US at a teaching hospital and get signed off that they’re safe to practice.

That’s a lot more scrutiny than midlevels where you can do an online NP and shadow for a few months and voila you’re ready!

The teaching hospital provision will also limit the reach of this a bit. Only a few residency programs in the state.

It’s not like they’re handing out licenses to Caribbean grads with no residency training.
How about an HCA GME location? Find the original TN bill and follow the money!
 
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Just for further safety, these docs still have to practice under some supervision for 2 years in the US at a teaching hospital and get signed off that they’re safe to practice.

Isn’t this basically a resident in their final years?
 
How about an HCA GME location?
They only have programs in a few specialties but presumably they have the infrastructure in place to supervise and sign off on these foreign docs.

TN has many areas with major physician shortages, as well as some areas like Nashville with a big surplus. Once out from under the umbrella of the supervising hospital, and with only a TN license, I’ll bet many of these grads gravitate toward those more rural yet highly paid areas.
 
Have to disagree. I’d take a fully licensed MD from the UK or Italy or Lebanon who has completed what’s usually a much longer residency than the US and been practicing independently in their home country for 3 years, over a US-trained midlevel any day. Just for further safety, these docs still have to practice under some supervision for 2 years in the US at a teaching hospital and get signed off that they’re safe to practice.

That’s a lot more scrutiny than midlevels where you can do an online NP and shadow for a few months and voila you’re ready!

The teaching hospital provision will also limit the reach of this a bit. Only a few residency programs in the state.

It’s not like they’re handing out licenses to Caribbean grads with no residency training.
I think every single state should do this for especially primary care with the stipulalion that these physicians have to work for 2-3 years in designated rural areas
 
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Isn’t this basically a resident in their final years?
Somewhat, though these docs would have much more experience in practice than a typical resident.

If these provisional licenses are allowed to bill for services, I’m sure they will get used more like junior attendings but with some oversight and review by senior physicians.
 
I think the care would be far better but physician salaries would plummet. Would be like EM for all specialties. Doing 3+ fellowships just to get a job
 
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This is a disaster and is the first step towards something that will be 10000x worse than mid level independent practice
How so? If they can pass the USMLE and can't get a full license until after working for several years in rural areas, how is this worse than an unsupervised nurse practitioner with an online degree practicing alone in a rural emergency department?
 
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I think every single state should do this for especially primary care with the stipulalion that these physicians have to work for 2-3 years in designated rural areas
Well I’d say maybe wait and see how it goes for TN first, but yes if it works out then worth expanding.

I wonder if the rural requirement will be necessary. Many of the foreign docs I know eyeing the US are doing so largely for the much higher salaries here, and the more rural locations typically pay far more than the saturated markets.

I’ll bet HCA shuffles these folks to their more remote community hospitals after their provisional period is done. No bill would ever pass in TN without HCA backing it, so I’m sure they crafted the language to their liking.

What will be interesting is if HCA uses this to bring in cheap labor that can actually bill, work them for a few years at vastly under market salaries (yet comparable to their home country) and then refuse to sign off on them. You could theoretically create a quasi indentured servant physician who can only work for you and just refuse to certify them for full licensure.
 
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I think the care would be far better but physician salaries would plummet. Would be like EM for all specialties. Doing 3+ fellowships just to get a job
Maybe over time, but I don’t think the pace of this program will be fast enough to have a big market effect. The hoops these docs have to jump through are massive. The caveat is if HCA and the like just keep these folks provisional while paying them peanuts.

There’s also the gatekeeper aspect of which specialties have an accredited residency. For example, a foreign ENT or neurosurgeon would have 2 options - UT or Vanderbilt. And those programs may not even participate in this endeavor. They also have a market interest in maintaining good relationships with referring docs. Saturating the market with other specialists is not a great way to do that.
 
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I don't see why foreign docs would gravitate to rural areas. Even academic US salaries are pretty high compared to most of their home countries, combined with much less, if any debt. And cultural/social factors depending on the area.
 
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I don't see why foreign docs would gravitate to rural areas. Even academic US salaries are pretty high compared to most of their home countries, combined with much less, if any debt. And cultural/social factors depending on the area.
Yeah it will be interesting to see. I suspect that the cost of living in the major areas plus the higher salaries just outside them may drive many of these docs out of the saturated markets.

Most of these docs will be older with families rather than young fresh US grads. They may not want to live in the middle of nowhere, but there are massive shortages within 45 minutes of the major cities. Lower housing costs, higher pay, better public schools, and shorter commute time would potentially be a big draw for older docs.
 
I don't see why foreign docs would gravitate to rural areas. Even academic US salaries are pretty high compared to most of their home countries, combined with much less, if any debt. And cultural/social factors depending on the area.
Because for them, living in rural TN is an improvement over practicing in, say, Yemen, Burma, Cambodia, either Sudan or Guatemala.
 
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The notable aspect of this, as mentioned in other posts, is that the overwhelming majority of residency spots in Tennessee are aligned with just two institutions. For example, 67% of IM spots and 80% of GS spots are through either UT or VUMC. It may be that, in practice, this primarily affects FM.

East Tennessee has one of the largest physician shortages in the nation, to my knowledge. I wouldn't be worrying about this causing significant competition for physicians state-wide.
 
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This seems to be more for FMGs with significant work experience who would likely have difficulty matching the conventional way. The real question is if this will lead to a funnel of these more experienced FMGs trying to go directly into practice with this program or if they will still try to apply for academic residency programs in the area. In order to maintain licensure they will likely still have to take Step 1 and 2 before they take Step 3. This will definitely benefit for profit hospitals like HCA though, who will definitely be able to just have a perpetual workhorse program of FMGs on top of their residency programs leading to reductions in cost.
 
This isn't going to be some "open the floodgates fearmongering" type of deal because the FMG needs to be a US citizen/PR/have a work permit when they apply. That's a significant bottleneck, and for those who haven't gone through the USCIS it is an absolutely huge time sink and PITA.

This is absolutely not going to cause physician comp to plummet because the number of FMGs getting through USCIS over time will be inconsequential to the total # of new physicians graduating per year. There isn't a "physician spot" for immigration, since IIRC USCIS currently works based off quotas and caps for each country (ofc this may change, but unlikely).
 
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This isn't going to be some "open the floodgates fearmongering" type of deal because the FMG needs to be a US citizen/PR/have a work permit when they apply. That's a significant bottleneck, and for those who haven't gone through the USCIS it is an absolutely huge time sink and PITA.

This is absolutely not going to cause physician comp to plummet because the number of FMGs getting through USCIS over time will be inconsequential to the total # of new physicians graduating per year. There isn't a "physician spot" for immigration, since IIRC USCIS currently works based off quotas and caps for each country (ofc this may change, but unlikely).
Wouldn’t hospitals like hca go above and beyond to sponsor them if it meant saving money on labor
 
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Wouldn’t hospitals like hca go above and beyond to sponsor them if it meant saving money on labor

It's very expensive to sponsor foreign workers and they can't just sponsor EVERYONE. The company needs to show that they have exhausted their options trying to fill the employment spot with US workers and that the foreign worker is the best option given the situation. It's not something they can do willy nilly.
 
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This isn't going to be some "open the floodgates fearmongering" type of deal because the FMG needs to be a US citizen/PR/have a work permit when they apply. That's a significant bottleneck, and for those who haven't gone through the USCIS it is an absolutely huge time sink and PITA.

This is absolutely not going to cause physician comp to plummet because the number of FMGs getting through USCIS over time will be inconsequential to the total # of new physicians graduating per year. There isn't a "physician spot" for immigration, since IIRC USCIS currently works based off quotas and caps for each country (ofc this may change, but unlikely).
Plenty of FMGs come over here and don't end up practicing but still get citizenship through other means. I met several in the Army who were serving in healthcare adjacent jobs (like environmental health or medical logistics) but had been doctors in their home countries.
 
Plenty of FMGs come over here and don't end up practicing but still get citizenship through other means. I met several in the Army who were serving in healthcare adjacent jobs (like environmental health or medical logistics) but had been doctors in their home countries.

Yeah, but you cannot serve in the military without a PR anyway. They would've been eligible for the new TN law in the first place whether they joined the military to receive a citizenship or not.

There are multiple ways of going from PR -> citizenship outside of waiting the 5 or something years to apply for naturalization, but there are very limited ways of going from no visa -> visa/PR. The latter is where the bottleneck exists.
 
This is interesting, is similar to the Assistant Physician bill. As mentioned, the number of people who will qualify for this is limited -- the bill clearly states that you need to be a US Cit or otherwise legally allowed to work in the US - I assume this means "without a visa". If not, then the number of people whom would qualify would be much larger and the hospital could just get them H visas.

The risk of abuse here is enormous. Anyone coming into this program would have no ability to push back against their employer -- so they could pay them anything, set any schedule, etc. There would be no oversight at all. And the bill doesn't define any supervision requirements. If this is HCA driven, I could imagine all sorts of shenanigans.
 
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Not sure how limited the pool of potential physicians really is. H visas definitely seem to be the intended means of getting workers here through this bill. There are only ~1 million physicians in the US, but there are ~13 million worldwide. Plenty of physicians from other countries come here even without a residency. It wouldn't take that many foreign physicians to flood the market and obliterate negotiating power.

HCA has gone on record saying their business strategy is to open so many residencies in certain specialties (e.g., EM) that they flood the market and make returns for their investors via wage suppression. It's literally direct wealth transfer from the labor class to the investor class. They are quite obviously supporting this and using it as another means of creating a labor surplus. I wouldn't be surprised if they even hired more physicians than they needed at extremely reduced rates and had them working in mid-level roles for mid-level wages just to fulfill the requirement, flood the market faster, and push down wages of their existing US-trained staff.
 
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What’s to stop a few “degree mills” from popping up around the world with no central accrediting agency? Seems like a lot of people would pay $$ to practice in the US. Seems like a slippery slope
 
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When I first read the bill/law, I interpreted it as requiring US citizenship. The more I look at it, I get the sense that "legally allowed to work in the US" would include on an H visa. If that's the case, then this is a wide open door. Employers would need to pay a prevailing wage (that's required for an H), but there's lots of wiggle room in that and I think they could argue for lower wages given that they would only have provisional licenses. There still would be no standard for supervision.

The bill requires a completed residency, so this isn't a "diploma mill" issue directly.
 
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The boards for each specialty will be the ultimate bottleneck. These doctors will have a hard time getting board certified without completing residency in the U.S.
 
What’s to stop a few “degree mills” from popping up around the world with no central accrediting agency? Seems like a lot of people would pay $$ to practice in the US. Seems like a slippery slope
ECFMG certification is getting big changes for 2024's match. I imagine that those applying to this program will likely have to obtain this certification as well.

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Because for them, living in rural TN is an improvement over practicing in, say, Yemen, Burma, Cambodia, either Sudan or Guatemala.

And better still, suburban and urban US (for most folks, anyway).


It's very expensive to sponsor foreign workers and they can't just sponsor EVERYONE. The company needs to show that they have exhausted their options trying to fill the employment spot with US workers and that the foreign worker is the best option given the situation. It's not something they can do willy nilly.

They‘ll find ways to represent “the situation” to best suit their interest$.

This may not be a horrible piece of legislation in and of itself. I’m undecided. But this is the first step in a direction few among us would ultimately agree with. What comes after this? If we accept that residency training in the US is no longer required to practice here, what will be the next standard that is slackened?
 
As someone foreign born who had a very hard time coming to the US when he was 12 years old, this seems like a disaster. Foreign docs have a hard time as it is assimilating to American residencies in urban areas. I couldn’t imagine putting them in a rural healthcare setting without a residency will go over well AT ALL.
 
Passed in Iowa

Arizona

Colorado



Weird thing is that they all appear to read nearly identically almost like an outside organization has written them all.



My guess is that there will be a lot of defaults on med school loans over the next 10 years
 
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Being able to practice and being able to bill are two entirely separate things. Someone with no residency training will not be board certified and thus ineligible to bill for most services under most insurance policies. You can give people medical licenses all you want, but they are worthless without actually being able to charge for their services. The other major issue is that privileges at most hospitals require board certification or board eligibility, something that would be impossible to get for someone using this pathway. Finally, no insurer would cover someone that hasn't completed US training. It's a proposal that looks good on paper but which does nothing in reality, aside from allowing uninsured physicians to run cash-only practices if they can find a hospital system that will let them practice for two years while not being able to bill a dime first.
 
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Being able to practice and being able to bill are two entirely separate things. Someone with no residency training will not be board certified and thus ineligible to bill for most services under most insurance policies. You can give people medical licenses all you want, but they are worthless without actually being able to charge for their services. The other major issue is that privileges at most hospitals require board certification or board eligibility, something that would be impossible to get for someone using this pathway. Finally, no insurer would cover someone that hasn't completed US training. It's a proposal that looks good on paper but which does nothing in reality, aside from allowing uninsured physicians to run cash-only practices if they can find a hospital system that will let them practice for two years while not being able to bill a dime first.
Why wouldn’t hospitals and or boards just change their policies. Would insurance possibly be able to pay less for these physicians? If so why not just alter their own rules. What if Medicare decides to reimburse them at similar rates?
 
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Why wouldn’t hospitals and or boards just change their policies. Would insurance possibly be able to pay less for these physicians? If so why not just alter their own rules. What if Medicare decides to reimburse them at similar rates?
Creating a second payor class would be legally and ethically dubious. Can you imagine the headlines painting systems as racist for underpaying foreign workers while pushing for NP pay parity?

Hospitals would open themselves to liability by bringing in unknown quantities. When you bring in someone board certified and trained in the US, you are putting it on those systems that these are competent practitioners, thus the liability falls on them until proof can be shown that the system neglected indications they were a problem. For a foreign-trained doctor the liability would be entirely on the hospital in a legal setting, as they would be the ones attesting to the doctor's competence rather than a board and the ACGME. That's a big can of worms to open. For similar reasons, liability coverage won't be obtainable because they represent an unknown quantity and insurance is all about calculating the risks of known quantities.

As to insurance companies, they want less doctors on their payrolls, not more. More doctors means more claims. They want the lowest legally justifiable number of physicians on their payroll that they can get away with, which is why their panels are often closed to join in many areas.

Now, on to Medicaid and Medicare. Medicare is very US-focused, for obvious political reasons. Changing it to favor foreign physicians would be a death knell for Republican lawmakers, as they would both be encouraging immigration and disadvantaging American workers. I was in DC recently advocating for the Conrad 30 to be extended and expanded and was told by one of the senior policy advisors for a member of the house that it's very touchy right now due to immigration in general abs the GOP wanting to be viewed as tough on immigration. I was like, "so you're telling me they would rather waste hundreds of thousands of dollars sending physicians we've already paid to train back to their home countries and let their own constituents go without care just because that care happens to be provided by an immigrant?" And the answer I got was, "unfortunately that isn't how their constituents see it, but yes, that's the ultimate effect."

The sky isn't falling, this will likely end up like the "Assistant Physician" law that got passed and resulted in basically no one practicing under its auspices for similar reasons.
 
The rest of the world has similar systems to recognize foreign educated physicians and allow them to intregrate.

If somebody:
  • Graduated from an accredited university
  • Passed the same medical license examination like anybody else in the US
  • Holds a legal permit to live in the country
  • Has completed a medical residency deemed equivalent by the respective american board
Then that person has the same competency to practice as their american counterparts

I think many people don't even know how rigorous the Accreditation Policy of the ECFMG is. It took my university 4 years to achieve the recognition of the WFME after the ECFMG announced such policy change. They even take into consideration things like how wheelchair accessible the campus is.

Many people in the US disregard the rest of the world's education as sub-par and think that the US healthcare system is the best in the world. When important figures such as accesibility and mortality rates say otherwise. Sure, salaries are ridiculously better than in any other country, but that's a symptom of systemic problems, a whole can of worms that I don't want to open right now.

Some people comparing international graduates that have completed 6 years of medical school + 5 (in many cases) years of residency and have years of experience, to mid-levels in the US. You need a psych consult, STAT.
 
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The rest of the world has similar systems to recognize foreign educated physicians and allow them to intregrate.

If somebody:
  • Graduated from an accredited university
  • Passed the same medical license examination like anybody else in the US
  • Holds a legal permit to live in the country
  • Has completed a medical residency deemed equivalent by the respective american board
Then that person has the same competency to practice as their american counterparts

I think many people don't even know how rigorous the Accreditation Policy of the ECFMG is. It took my university 4 years to achieve the recognition of the WFME after the ECFMG announced such policy change. They even take into consideration things like how wheelchair accessible the campus is.

Many people in the US disregard the rest of the world's education as sub-par and think that the US healthcare system is the best in the world. When important figures such as accesibility and mortality rates say otherwise. Sure, salaries are ridiculously better than in any other country, but that's a symptom of systemic problems, a whole can of worms that I don't want to open right now.

Some people comparing international graduates that have completed 6 years of medical school + 5 (in many cases) years of residency and have years of experience, to mid-levels in the US. You need a psych consult, STAT.
Do other countries charge 400k for medical school at 8.5%
 
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Do other countries charge 400k for medical school at 8.5%
I'll quote myself . "symptom of systemic problems, a whole can of worms that I don't want to open right now"

The cost of education isn't an argument against recognizing foreign professionals
 
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I'll quote myself . "symptom of systemic problems, a whole can of worms that I don't want to open right now"

The cost of education isn't an argument against recognizing foreign professionals
Don’t residents work like 30 hours per week in Europe. In what world is that equivalent to US training
 
Don’t residents work like 30 hours per week in Europe. In what world is that equivalent to US training

40-50 hours per week is the norm. But it takes at least twice as many years to finish

As an example, with "normal" and "humane" working hours
A friend just finished Neurology after 8 years
A colleague did Adult + CA Psych in 9 years
 
The rest of the world has similar systems to recognize foreign educated physicians and allow them to intregrate.

If somebody:
  • Graduated from an accredited university
  • Passed the same medical license examination like anybody else in the US
  • Holds a legal permit to live in the country
  • Has completed a medical residency deemed equivalent by the respective american board
Then that person has the same competency to practice as their american counterparts

I think many people don't even know how rigorous the Accreditation Policy of the ECFMG is. It took my university 4 years to achieve the recognition of the WFME after the ECFMG announced such policy change. They even take into consideration things like how wheelchair accessible the campus is.

Many people in the US disregard the rest of the world's education as sub-par and think that the US healthcare system is the best in the world. When important figures such as accesibility and mortality rates say otherwise. Sure, salaries are ridiculously better than in any other country, but that's a symptom of systemic problems, a whole can of worms that I don't want to open right now.

Some people comparing international graduates that have completed 6 years of medical school + 5 (in many cases) years of residency and have years of experience, to mid-levels in the US. You need a psych consult, STAT.
It isn't about whether it is good or not, it is about whether it is a known quantity or not. There are absolutely countries with lower quality GME than the United States, or even programs within countries that otherwise have high-quality GME. There's a lot of countries where greasing palms with cash can turn failure to a pass. We have no idea what the local reputations of given programs are, nor what their training standards are, nor whether these standards are directly comparable to those in the United States. This represents an unknown quantity. A foreign physician may be a superstar, or they may be hot garbage, we have no standardized way of knowing. We at least know that those completing ACGME training have met a certain standard of competence and that their program was of a reasonable level of quality. Even within the United States, AOA programs were considered an unknown quantity and many employers would not hire graduates from these programs in fields like radiology or anesthesia, and these were people that were trained domestically.

When a quantity is unknown, you, as an employer or insurer, take on the burden of that uncertainty. That is a very big deal in a country where lawsuits can rise to tens of millions of dollars. Even if it isn't the quality of the physician's previous training that caused an error, this is what negative outcomes will be blamed upon, and it will be pitched as negligence that a hospital hired such a physician without vetting them more carefully. This burden does not exist with the ACGME, as you are considered to have met the acceptable US standard of training. This is critical in understanding how health systems function. Your primary role, to them, is not patient care. It is to be a revenue generator and a liability sponge. Both of these roles are substantially compromised by anyone qualified under this law.
 
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Creating a second payor class would be legally and ethically dubious. Can you imagine the headlines painting systems as racist for underpaying foreign workers while pushing for NP pay parity?

Hospitals would open themselves to liability by bringing in unknown quantities. When you bring in someone board certified and trained in the US, you are putting it on those systems that these are competent practitioners, thus the liability falls on them until proof can be shown that the system neglected indications they were a problem. For a foreign-trained doctor the liability would be entirely on the hospital in a legal setting, as they would be the ones attesting to the doctor's competence rather than a board and the ACGME. That's a big can of worms to open. For similar reasons, liability coverage won't be obtainable because they represent an unknown quantity and insurance is all about calculating the risks of known quantities.

As to insurance companies, they want less doctors on their payrolls, not more. More doctors means more claims. They want the lowest legally justifiable number of physicians on their payroll that they can get away with, which is why their panels are often closed to join in many areas.

Now, on to Medicaid and Medicare. Medicare is very US-focused, for obvious political reasons. Changing it to favor foreign physicians would be a death knell for Republican lawmakers, as they would both be encouraging immigration and disadvantaging American workers. I was in DC recently advocating for the Conrad 30 to be extended and expanded and was told by one of the senior policy advisors for a member of the house that it's very touchy right now due to immigration in general abs the GOP wanting to be viewed as tough on immigration. I was like, "so you're telling me they would rather waste hundreds of thousands of dollars sending physicians we've already paid to train back to their home countries and let their own constituents go without care just because that care happens to be provided by an immigrant?" And the answer I got was, "unfortunately that isn't how their constituents see it, but yes, that's the ultimate effect."

The sky isn't falling, this will likely end up like the "Assistant Physician" law that got passed and resulted in basically no one practicing under its auspices for similar reasons.
Excellent points.

To what extent do you think an entity like HCA could circumvent this? They already self insure so they have malpractice covered internally. The new docs will be licensed and should have NPI numbers and be able to bill CMS payors. Getting on the panels with the commerical payors I'm not sure about, though HCA would certainly have leverage in many markets to make this happen. There are many areas where HCA hopsitals are the only option.

The more I think about this, I'll bet HCA and similar entities are planning to use this to bolster their EM and IM workforce for well below market rates. They're basically getting residents who can bill and still have no power to leave and work elsewhere.

Your points are well taken and are likely why we won't see a bunch of FMGs hanging out shingles in East Tennessee anytime soon.
 
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