Exclusion of International Medical Graduates From Federal Health-Care Programs

Abstract

The professional standards of international medical graduates have been the subject of controversy, but empirical research on this topic has been limited. This report considers whether international medical graduates are at greater risk than US medical graduates for exclusion by the federal government from federally funded programs, such as Medicare and Medicaid. The list of excluded physicians was merged with data regarding 87,729 family and general practice physicians from the American Medical Association Physician Masterfile, 555 of whom were currently excluded. Logistic regression was used to estimate the effect of international medical graduate status on the probability of exclusion, controlling for board-certification status and other physician characteristics. International medical graduates from high-income Organization for Economic Cooperation and Development (OECD) countries are distinguished from other international medical graduates. The adjusted exclusion rates of international medical graduates from OECD countries were similar to that of US medical graduates. Among board-certified physicians, the relative risk of exclusion of non-OECD international medical graduates was 2.19 (P <0.001) compared with US medical graduates. Board certification had an even stronger association: US medical graduates who had never been board certified had a relative risk of 4.12 (P <0.001) compared with board-certified US medical graduates. The never board-certified relative risk was 1.72 (P <0.001) among non-OECD international medical graduates compared with board-certified graduates. Among physicians who had never been board certified, rates of US and international medical graduates did not differ substantially. Further investigation is needed regarding the causal determinants of exclusion disparities. It is unclear to what extent these disparities may reflect differences in ethical conduct, quality of care, or prejudicial enforcement practices, and the extent to which board certification can causally reduce actions leading to exclusion.