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EHR vendors could be forced to pay higher salaries for healthcare software developer jobs under a Trump administration plan to tighten the H-1B visa program for skilled foreign guest workers.
The H-1B program was a frequent target of President Donald Trump during the presidential campaign. Trump assailed the program's lack of enforcement for allowing U.S. companies to exploit loopholes to hire foreign workers at below-market salaries instead of paying American workers higher average wages for the same positions.
Trump on April 18 signed an executive order to study reforms to the program by tightening enforcement and changing the existing visa lottery system from a random first-come, first-served process to a lottery only for the most skilled and highest-paid workers.
Cerner heavy user of H-1B visas
Cerner Corp., one of the two biggest developers of EHR systems, is also the health IT industry's biggest user of H-1B visas, sponsoring from 200 to more than 600 foreign workers a year for three-year healthcare software developer and similar jobs.
Since 2013, Cerner has sponsored 1,841 H-1B visa applications, according to myvisajobs.com, ranking the Kansas City, Mo., company 55th among all U.S. corporations and eighth in seeking to hire foreign workers for software developer jobs via the H-1B program, as of May 2017.
Some 77% of those jobs were classified as level one, or the lowest of four H-1B pay classifications, and paid an average of $76,364 -- below the average wage for healthcare software developer jobs in Cerner's home region and the U.S. as a whole. Critics say tech companies classify workers lower to pay workers below the average local wage.
Dan Smith, a Cerner spokesman, declined comment on any potential changes to the program. But he said Cerner needs a robust supply of skilled foreign workers because of a shortage of software developer talent in the U.S. And the company, meanwhile, is intensifying domestic recruiting and training efforts with schools and universities.
"These highly skilled guest workers are part of the reason we're successful today," Smith said. "This recruiting is designed to address the shortage of technical talent."
Notably, amid Trump's push to reform the system, Cerner, in particular, has dramatically ramped up the number of its H-1B applications. In 2017 alone, the company has applied for at least 636, double the number of any in the previous four years, according to myvisajobs.com.
One health IT observer, John Moore, founder and managing partner of Chilmark Research in Cambridge, Mass., said he sees nothing wrong with the visa program or Cerner's reliance on foreign workers for healthcare software developer jobs, in addition to local talent.
"The H-1B program is a good way of bringing talent into the United States," Moore said. "It gives an opportunity to those from other countries to come to the United States and contribute to the growth of our economy. It's a global win, as well, because often these people are sending money back to their families."
Referring to Cerner's rapid expansion due to acquisition and a big federal contract, Moore said "they've been growing at such a tear for all these years, they still can't meet all the resource needs that they have."
Outsourcing companies singled out
Meanwhile, the bulk of H-1B visas -- which can be renewed for a second three-year period -- go to lesser-skilled, lower-paid workers sponsored in large numbers by big outsourcing companies, some of which Trump targeted by name April 18.
Trump's outsourcing stance echoed liberal former Democratic presidential candidate and H-1B critic Bernie Sanders' position, and it reflects how the H-1B issue doesn't break down along traditional political lines.
The program has been popular among the biggest Silicon Valley tech companies, such as Facebook, Apple and Google, which rely heavily on H-1B workers.
Ron Hiraassociate professor of public policy at Howard University
But ending the random lottery approach could force companies like Cerner to pay more for software developer jobs if the employers want to "win" H-1B lotteries, said Ron Hira, associate professor of public policy at Howard University in Washington, D.C., and a prominent critic of the program.
"You've got to be careful about saying there's a shortage of American workers. There's a shortage of Americans willing to work for H-1B wages," Hira said in an interview. "H-1B allows you to legally pay a lot less than the market wage, and you'd be stupid not to take advantage of that if you're an employer."
Besides Cerner, no other exclusively health IT companies are in the top 100 corporate H-1B users, though outsourcing companies that dominate the top 100 list, such as the ones Trump mentioned -- Tata Consultancy Services, Infosys and Cognizant -- do business in healthcare, particularly with insurance payers.
Cerner not only EHR vendor with H-1Bs
A spokeswoman for Epic declined comment on the company's use of foreign guest workers, which, while less intensive than Cerner's, is considerable. The Verona, Wis., vendor likely needs fewer foreign workers because of its direct hiring pipeline from the University of Wisconsin in neighboring Madison.
Two of the leading ambulatory EHR vendors, eClinicalWorks and athenahealth, Inc., did not respond to repeated requests for comment.
Based in Westborough, Mass., eClinicalWorks ranked second to Cerner among health IT vendors over the last five years in number of H-1B visas it sponsored, though it is a much smaller company. Founded by an Indian immigrant, Girish Navani, eClinicalWorks employs hundreds of Indian H-1B workers and outsources much of its technical support to India.
Nearly 70% of H-1B workers are from India, with the second biggest group coming from China -- about 12%, according to The New York Times.
One of eClinicalWorks' main competitors, athenahealth, has sponsored relatively few H-1Bs, but the Watertown, Mass., firm relies heavily on outsourcing to India for billing and other services.
Providers and H-1B
Healthcare systems are not as dependent on H-1B guest workers as the biggest health IT vendors and are not as likely to be affected by Trump's proposed changes because they are already paying guest workers in the higher salary range.
For example, in 2016, healthcare software developer jobs with an average salary of $77,165 accounted for 335,052 H-1B applications, while hospital jobs such as physician made up 7,765 H-1B applications for jobs with an average salary of $123,860, according to myvisajobs.com.
Teaching hospitals, however, are among nonprofit organizations that are granted an unlimited number of H-1B visas, unlike private industry, for which H-1Bs are capped at 65,000 a year.
For health IT vendors such as Cerner, if changes to H-1B envisioned by Trump go through, costs will likely go up and customers would feel the effects.
"You've got to take it out of somewhere, whether it's higher prices for software, or less research and development," Moore said.
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