Foreign Medical Schools:

Education Should Improve Monitoring of Schools That Participate in the Federal Student Loan Program

GAO-10-412: Published: Jun 28, 2010. Publicly Released: Jun 28, 2010.

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Each year, the federal government makes a significant financial investment in the education and training of the U.S. physician workforce. A quarter of that physician workforce is composed of international medical graduates (IMG) and they include both U.S. citizens and foreign nationals. In fiscal year 2008, the federal government loaned $633 million to U.S. students enrolled in foreign institutions--including medical students--through the Federal Family Education Loan (FFEL) program. The government also makes a substantial domestic investment in the graduate training of the physician workforce. For example, in fiscal year 2008, federal support for residency training in the United States amounted to nearly $9 billion. As with medical students educated in the United States, this training is required of all IMGs--U.S. citizens and foreign nationals alike--who seek to practice medicine without supervision in the United States. The Department of Education (Education), which administers the federal student loan program, must also monitor foreign schools that seek to participate in the program with respect to specific statutory requirements. Among these is the statutory requirement that at least 60 percent of their students who take the U.S. medical licensing exam must pass the exam. Most recently, Congress increased the pass rate to 75 percent, effective July 2010. Little is known about IMGs with respect to how much they borrow overall, or the outcome of their medical studies, leading some policy makers to question the federal return on investment in IMGs. Therefore, Congress mandated that GAO study the performance of IMGs educated at these schools and other aspects of a foreign medical education, including the potential effect of the new 75 percent pass rate requirement on school participation in the federal loan program. This report examines the following questions: 1) What amount of federal student aid loan dollars has been awarded to U.S. students attending foreign medical schools? 2) What do the data show about the pass rates of international medical graduates on license examinations? 3) To what extent does Education monitor foreign medical schools' compliance with the pass rate required to participate in the federal student loan program? 4) What is known about schools' performance with regard to the institutional pass rate requirement? 5) What is known about where international medical graduates have obtained residencies in the United States and the types of medicine they practice?

In summary, we found the following: 1) From 1998 to 2008, U.S. students enrolled at foreign medical schools borrowed $1.5 billion in FFEL loans to attend free-standing medical schools. Although this amount represents less than 1 percent of all federal student loans borrowed during this period, borrowing has grown significantly, in part because of increases in tuition, student enrollments, and the availability of additional loan funds for graduate and professional students. 2) IMGs, as a group, have consistently passed their medical licensing exam at lower rates over the past decade than their U.S.-educated peers, but have narrowed this performance gap for most of the exam steps. 3) Education has not been able to fully enforce the institutional pass rate requirement needed for continued federal student loan eligibility. The three private organizations that administer each step of the exam have declined to release student scores on grounds that the data are proprietary in nature and should not be used for marketing purposes. As a result, Education reviews pass rates only when a school applies for the program, when it periodically seeks recertification, or when there is a change in ownership. 4) Our own analysis of 2008 pass rate data of institutions located in countries that participate in the federal loan program indicates that while a majority of foreign medical schools in these countries met the current 60 percent student pass rate requirement, very few--11 percent--would likely meet the newly required 75 percent pass rate. 5) IMGs have entered into residency programs in all states, though they are concentrated in the eastern United States, and a larger proportion tend to practice in primary care than do U.S.-educated graduates. Nationwide, in academic year 2008-2009 there were 109,482 medical residents, over 30,000 of whom were IMGs (about 27 percent). Overall, few significant differences exist between all IMGs and U.S.-educated physicians with regard to either disciplinary actions that would revoke or suspend their licenses or with regard to malpractice payments--and rates of disciplinary actions are low for physicians as a whole. GAO is making several recommendations to the Department of Education concerning the lack of student consumer data on foreign medical institutions and also the department's monitoring of pass rates for foreign medical schools whose students take the U.S. medical licensing exam. We provided a draft of this report to the Departments of Education and Health and Human Services (HHS). Education agreed with our recommendations and plans to collect consumer information on foreign medical schools. In its comments, HHS noted that increasing the pass rate requirement will adversely affect federal student loan availability for future students attending foreign medical schools, adding that IMGs contribute a significant percentage of primary care residents in the United States.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: Education issued a Dear Colleague Letter in November 2012 requiring international medical schools participating in the direct loan program to provide data on completion rates and mean and median student debt levels by April 30, 2013 (and annually thereafter, by April 30). The updated consumer information was published on Education's public website in 2013 (www.studentaid.gov).

    Recommendation: To enhance information available for prospective students of foreign medical schools and strengthen monitoring of foreign medical schools participating in the federal student loan program, the Secretary of Education should collect consumer information, such as aggregate student debt level and graduation rates, from foreign medical schools participating in the federal student loan program as recommended by the National Committee on Foreign Medical Education and Accreditation and make it publicly available to students and their families.

    Agency Affected: Department of Education

  2. Status: Closed - Implemented

    Comments: The Department of Education sent a letter to foreign medical schools asking for US Medical Licensing Examination (USMLE) pass rate information starting with exams taken during the award year ending June 30, 2010. They followed the correspondence to schools with a July 2011 Federal Register notice. ED subsequently issued a July 2011 Federal Register notice in which the Secretary required that 2010 pass rate data be submitted by September 30, 2011 and data for all subsequent years be submitted by April 30.

    Recommendation: To enhance information available for prospective students of foreign medical schools and strengthen monitoring of foreign medical schools participating in the federal student loan program, the Secretary of Education should require foreign medical schools to submit aggregate institutional pass rate data to the Department annually.

    Agency Affected: Department of Education

  3. Status: Closed - Implemented

    Comments: In January 2011, the Department of Education sent a formal request to the Educational Commission for Foreign Medical Graduates (ECFMG) that they compute and provide to the department, on an annual basis, the school-level U.S. Medical Licensing Examination (USMLE) pass rates for foreign graduate medical schools. ECFMG did not agree to provide this testing data directly to Education, but offered to provide the data to the schools, which could in turn provide it to Education. ECFMG has subsequently agreed to verify the authenticity of the pass rate reports that schools would provide to Education, upon request.

    Recommendation: To enhance information available for prospective students of foreign medical schools and strengthen monitoring of foreign medical schools participating in the federal student loan program, the Secretary of Education should verify data submitted by schools, for example by entering into a data sharing agreement with the testing organizations.

    Agency Affected: Department of Education

  4. Status: Closed - Implemented

    Comments: The Department of Education's Assistant Secretary of the Office of Postsecondary Education sent a letter to members of Congress dated September 28, 2012. The enclosure to the letter summarized the results of Education's evaluation of increasing the pass rate threshold on the licensing exams from 60 to 75 percent. Based on its evaluation, Education deemed the new 75 percent threshold appropriate. To enable the Department to enforce the pass rate requirement, Education strongly recommended that Congress require the private organizations that administer the exams to provide directly to the department the data necessary to calculate pass rates for individual foreign graduate medical schools. Education also advised that the higher pass rate threshold apply to all schools, including those in Canada and for-profit schools, to the extent that the rate is used to determine the comparability of those schools to U.S. schools.

    Recommendation: To enhance information available for prospective students of foreign medical schools and strengthen monitoring of foreign medical schools participating in the federal student loan program, the Secretary of Education should evaluate the potential impact of the newly enacted 75 percent pass rate requirement on school participation in the federal student loan program and advise Congress on any needed revisions to the requirement.

    Agency Affected: Department of Education

 

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