Image by Mohamed Hassan from PixabayAs nursing and physician shortages continue, ambulatory surgery centers (ASCs) are seeking to recruit talent from other countries to fill the gaps.
However, new regulations and government red tape are making it harder to hire that talent.
“If any employer thinks they could succeed or keep any system with 100% domestic workers, they are not in touch with reality,” Ann-Rose Johnson-Lewis, director of legal services at WorldWide HealthStaff Solutions, told ASC News.
ASCs frequently use visa-linked staffing to hire physicians, including specialists from other countries, for outpatient roles. Among all clinical occupations, immigrants represent about 27% of physicians in the U.S., according to KFF data. About 19% of physicians are naturalized citizens and another 8% are noncitizen immigrants.
Due to ongoing nursing shortages in the U.S., centers also commonly recruit foreign-educated nurses through visa programs, such as the EB-3 immigrant visa, which provides a pathway to permanent residency.
Many roles that require a bachelor’s degree or higher can be sponsored through the H-1B visa program, too.
For ambulatory care, this includes positions such as physical therapists, occupational therapists and speech-language pathologists.
“Patients need to be taken care of, and a diverse global workforce is still a good option for health care employers,” Johnson-Lewis said.
Based in Charlotte, North Carolina, WorldWide HealthStaff Solutions helps nurses, health care professionals and their families immigrate to the U.S.
Visa types for ASCs
The three most common visa programs used by ASCs are the EB-3, H-1B and J-1.
The EB-3 is a permanent visa option for professionals and skilled workers. Nurses often qualify under Schedule A, which can expedite the process.
J-1 visas mainly support exchange visitors, including foreign doctors coming to the U.S. for graduate medical training. A quarter of the practicing physicians in the US. are international medical graduates (IMGs).
A 2018 study by the Bureau of Health Workforce found that these graduates, whether born in the U.S. or not, are more likely than U.S. medical graduates to work in shortage areas, such as rural communities. Many IMGs complete residency training on J-1 visas, which require them to return to their home country for 2 years. However, many transition to H-1B status through a federal program called the Conrad 30 waiver, which allows IMGs to remain in the U.S. if they commit to three years of work in a medically underserved community.
H-1B visas are temporary, non-immigrant visas for specialized jobs that require at least a bachelor’s degree.
These visas are often used to sponsor physicians and allied health professionals. The H-1B program is capped at 85,000 visas annually, and applications usually take about 6 months to process.
Visa sponsorship is a crucial tool for ASCs to address labor shortages and attract qualified talent in a competitive market. Centers may also provide additional benefits such as relocation assistance, licensing support and housing to draw in international talent.
Between 2001 and 2020, the Conrad 30 waiver recruited 18,504 physicians, resulting in a 111% increase in annual recruitment and a reduction in unfilled state positions from 950 to 338 during that period, according to a study published in JAMA Health Forum.
Still, hiring international talent and navigating the visa process can be complicated. To make the hiring process easier, ASCs often work with specialized health care staffing agencies. These agencies serve as the direct employer and visa sponsor, then assign the international health care worker to a client facility.
International hiring challenges
The main challenges to employing international talent are visa availability, followed by prolonged processing times and unforeseen legislative changes, according to Johnson-Lewis.
Johnson-Lewis explained that each visa category has a specific cap, and the problem is supply and demand.
More people are applying for visas than there are visas available, which affects processing times and availability.
“The H-1B is faster to process, so it is more attractive to employers,” Johnson-Lewis noted. “However, when you look at the applicants, the volume and the availability, that is by far the most challenging issue that health care employers face and will continue to face, unless there are significant changes – and we have to rely on Congress to do that.”
Often, ASCs focus on long-term plans, such as opening a new facility that needs to hire international talent to fill vacancies that can’t be filled due to shortages in the U.S.
“Domestically, right now, fewer people are taking and passing the National Council Licensure Examination (NCLEX), which all nurses must pass,” Johnson-Lewis said. “That number continues to decline and has been declining for the past 10 years. So, the pool of domestic employees isn’t sufficient for employers to draw from. They have to look internationally, considering both immediate needs and long-term strategies. However, because visas involve costs, there is also time involved in planning the investment.”
Johnson-Lewis explained that her team’s role includes educating employers that international hiring is not an immediate process. While it is possible, wait times of up to two and a half years may occur. International recruiting involves evaluating the applicable visa category and guiding employers through that process.
Then, there’s also the financial investment to consider.
Historically, there was no fee for the H-1B visa itself. Even so, there was a lottery registration fee of $10 that increased to $215 last year, Johnson-Lewis noted. Employers would also incur a filing fee, which is typical when applying for a visa.
A new $100,000 fee per application has caused controversy, especially for nonprofit hospitals in rural areas that may be hard-pressed to afford it, according to Johnson-Lewis.
“It’s essentially a non-starter for a nonprofit organization, like a hospital system,” Johnson-Lewis said. “For example, some hospital systems that benefit from this are those with higher vacancy rates, many of which are in rural America. If you’re considering a small hospital in rural Minnesota, bringing in nurses at $100,000 each isn’t feasible. It’s not sustainable for health care.”
The Trump administration imposed the fee in September on all new H-1B visa applicants living abroad. A clarification from U.S. Citizenship and Immigration Services on Oct. 20 said that this fee applies specifically to visa applications filed on or after Sept. 21 for workers outside the U.S. who are not current H-1B visa holders and must be paid before applying.
Health care workers may seek exemptions where hiring the worker serves the best interest of the nation, but exemptions are rare.
In announcing the new policy on Sept. 19, President Trump said the new fee was necessary to “address the abuse of that program while still permitting companies to hire the best of the best temporary foreign workers.”
On Sept. 29, Richard J. Pollack, president and CEO of the American Hospital Association (AHA), sent a letter to the U.S. Department of Homeland Security urging that health care workers be exempted from the increased fee.
“We believe that recruiting qualified foreign-trained medical professionals is an effective short-term approach that is vital to ensuring access to care in communities across the country,” Pollack wrote. “Of the almost 400,000 H-1B petitions approved in fiscal year 2024, 16,937 of those were for medicine and health occupations, and half of those approved petitions are for physicians and surgeons.”
The letter went on to say that the AHA is concerned that the policies established by the proclamation would undermine U.S. hospitals’ ability to hire H-1B visa holders for their facilities.
“This constraint will be felt most by our rural and underserved communities, which already face challenges in hiring and retaining staff to serve their patients,” Pollack said.
‘Important and productive relationships’
Earlier this month, the U.S. Chamber of Commerce sued the Trump administration over the foreign worker visa fee, calling it unlawful. This is the second complaint to be filed challenging the fee, with a coalition of health care groups and labor unions also challenging the policy’s legality in a lawsuit filed on Oct. 3.
Henry Ford Health, which provides ambulatory care services throughout Michigan, is one health system keeping a close eye on the situation.
“We rely on – and deeply value – the talents of our international team members; we’ve long held important and productive relationships with the international medical and research communities,” a spokesperson told ASC News. “We are currently analyzing the recently announced changes to the H-1B visa program and determining how it might impact our operations and dedicated workforce.”
Henry Ford Health offers ambulatory surgery across multiple locations, including Henry Ford Medical Center – Grosse Pointe and Henry Ford Medical Center – Royal Oak.
International talent is interested in working in the U.S. because it remains one of the countries that offers higher salaries.
Additionally, some international workers have family in the U.S., and finding employment here allows them to reconnect, Johnson-Lewis said.
“They have the opportunity to enjoy a better quality of life and raise a family here, so many people still look to the U.S. for that reason,” she said.
She explained that the U.S. has not made significant or comprehensive changes to immigration rules or regulations since 1986. This has led people to mainly enter the country through a visa-specific program or to seek asylum or refugee status. The current administration is working to make that asylum program more restrictive.
One of those restrictions is increasing the H-1B visa fee. Therefore, Johnson-Lewis said there is a need for comprehensive immigration reform, not just to support the international workforce but also to reduce the burden on domestic employers.
“If an employer is looking to sustain its workforce, international employees are a way they could always maintain that sustainability,” Johnson-Lewis said.
