Academy Urges Repeal of Mid-Level Provider Rule for Rural Health Clinics

The AAFP has called for an end to a federal requirement that rural health clinics have a nonphysician health care provider on site for at least 50 percent of the time the clinic is open.

The call comes in a letter from AAFP Board Chair Larry Fields, M.D., of Flatwoods, Ky., to Sen. Max Baucus, D-Mont., chair of the Senate Finance Committee, and Sen. Charles Grassley, R-Iowa, ranking member on the committee. In the letter, Fields urges Congress to repeal "an outdated and unnecessary statutory provision" in the Rural Health Clinics Act of 1977. That provision defines a rural health clinic as a facility that provides the services of a nurse practitioner, physician assistant or certified nurse-midwife "not less than 50 percent of the time the clinic operates."

Acknowledging the law originally was intended to increase rural residents' access to health care services, Fields said the requirement now limits staffing flexibility for family physicians who operate rural health clinics. An informal survey of AAFP members indicated "that it is frequently easier to recruit and employ a physician than it is to find a mid-level practitioner," Fields said in the letter. "In such instances, AAFP members have been threatened with decertification, even though all care was being delivered by physicians."

Part of the challenge may stem from shifting practice patterns for nonphysician practitioners, according to the Scope of Practice Partnership, a recently formed coalition of national medical specialty organizations and state medical societies established by the AMA. Trends indicate that mid-level providers are moving toward subspecialization and urban/suburban settings.

A 2004 report (PDF file: 32 pages, 225 KB. More about PDFs.) from the American Academy of Nurse Practitioners, for example, indicates that 1.6 percent of its members -- down from 2.4 percent in 1989 -- practiced in communities of fewer than 1,000 people and 18.7 percent of its members -- down from 22.7 percent in 1989 -- practiced in communities of 1,000 to 24,999 people.

To rectify the problem, Fields urged Congress to tweak the law to allow rural health clinics to employ nonphysician practitioners or physicians, "whichever is available and deemed to provide the highest quality of care."