Adam Cohen’s Report on the TN Department of Health J-1 Waiver Webinar

Posted on: September 17th, 2015
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On August 18th, 2015, the Tennessee Department of Health held a J-1 waiver webinar in order to review the state of TN’s Conrad program. The webinar was led by Ann Cranford, Director of the Recruitment & Retention Program at the Department of Health. She is the long-time program coordinator for the TN Conrad program.

Ms. Cranford stated that TN only used 8 of its 30 slots last year, and the Department of Health is hoping to increase this number. The low usage of TN’s Conrad program is due in part to the fact that portions of TN also come within the jurisdiction of the Delta Regional Authority (DRA) and the Appalachian Regional Commission (ARC). Both federal agencies can recommend unlimited J-1 waivers. The DRA is an excellent, open, and widely used program, which recommends several J-1 waivers in Western TN. The ARC is a more restrictive program, which can recommend J-1 waivers in Eastern TN, but it is unclear if the program has been used in TN in recent years.

Another reason for the low usage of TN’s Conrad program has to do with the fact that the program hasn’t been updated in years. Ms. Cranford was very open to our suggestions about how to improve and update the program.

My first suggestion to Ms. Cranford was for TN to eliminate its Health Resource Shortage Area (HRSA) designation, which is its own underserved designation for primary care specialties. Primary care physicians in TN must not only be placed in a federally designated underserved area (HPSA or MUA), but the work location must also be in a HRSA. This is more onerous that most other Conrad programs, which simply require placement in a federally designated underserved area. Moreover, according to the TN HRSA maps provided on the Department of Health’s website, the designations have not been updated since 2004 and therefore do not reflect TN’s current priorities. Ms. Cranford indicated that the Department of Health has discussed eliminating these designations, but no decision has been made as of yet.

My second suggestion was for TN to drop its one subspecialist slot per facility requirement. The problem is that while 70% of TN’s slots are reserved for primary care, only 30% are left for subspecialists. If those 30% of slots have not been used by April 1st, more than one subspecialist may be considered per facility at that time. If those 30% of slots have been used, the second subspecialist would have to wait until June 30th. For a state that only used 8 slots last year, there does not appear to be any good reason why the one subspecialist per facility rule and the 70%/30% division need to exist. The program should be opened up more like the Arkansas program and the DRA, for example.

My third suggestion had to do with the April 1st and especially June 30th dates noted above. These dates are very out of sync with the graduate medical education cycle. Most physicians’ programs end on June 30th, and foreign physicians only have a 30 day grace period on their J-1 status thereafter, unless they are either out of cycle on their training or they can secure a J-1 extension, such as for a board exam. The fact that TN opens up the program to a commendable degree after June 30th means nothing in practice, because very few physicians stand to benefit, and TN will likely receive no applications after that date. Rather, the catch-all opening of the TN program should be moved back to February 1st. In that way, TN can keep its priorities in place from October 1st (the start of the fiscal year) until February 1st, and thereafter, TN can open its program up further and receive several more applications.

A great suggestions came from a colleague of mine who noted that the requirements are too high for TN’s 10 authorized FLEX waivers. If the employer is not located in an underserved area, it must show that at least 50% of its patients reside in underserved areas. The is a very high percentage compared with other Conrad programs.  As my colleague noted, TN Conrad program officials know the state and its priorities.  Why can’t they use this knowledge to make FLEX decisions, rather than requiring documentation of such an onerous percentage?

Hopefully, the TN Department of Health will carefully evaluate our suggestions. Much of this policy comes from TN regulations, so it will be a more challenging process for changes to be effected.

Lastly, I would just like to leave my readers with a few notes from Ms. Cranford:

  1. All non-profit hospitals are now required to submit a copy of their Community Health Needs Assessment (federally required every 3 years) along with their J-1 waiver packet.
  2. TN accepts a statement that a physician will work “an average of” 40 hours.
  3. The TN program will at times conduct site visits to ensure compliance with the Conrad program. Ms. Cranford, herself, conducts the visits.


Please feel free to contact me at with any questions.