PHYSICIAN ASSISTANTS AND NURSE PRACTITIONERS IN RURAL
Who is providing healthcare to rural America and how are
policies incentivising healthcare providers to serve these geographical areas.
Physician assistants and nurse practitioners in rural medicine.
You are listening to ReachMD XM 157, the channel for
medical professionals. Welcome to the clinician's roundtable.
Ron Nelson, Physician Assistant and the President of Health
Services Associates in Fremont, Michigan, a firm that specializes in rural
health system development. Ron is the cofounder and First President of the
National Association of Rural Health Clinic and the past President of The
American Academy of Physician Assistants.
Hi Ron. Welcome to ReachMD.
Hi Thank you for the opportunity here today.
Ron, what is the Rural Health Clinic and what does it mean
to be a certified Rural Health Clinic?
A federally certified Rural Health Clinic is an institute
that has made a decision to go through a process of evaluation by state and
federal government to establish first of all that is an underserved area based
on certain criteria established by the Federal Government and secondly that it
must be staffed 50% of the hours by a nurse practitioner or physician
And what are the benefits of being certified as a Rural
The initial impetus for the development of this program was
during the current administration and recognition of lack of access in those
rural areas as well as a lack of mechanism to pay for non-physician providers.
So, 2 things happened in the program, 1 mechanism to incentivize via a cost
based reimbursement method and secondly the ability to pay for PAs and nurse
practitioners the same as paying for physicians for providing services to
Medicare and Medicaid patients.
What is the cost based reimbursement?
Cost based reimbursement is a method to look at the cost of
an organization or a cost that an organization incurs and calculate a mechanism
to pay for those services based upon the cost divided by the total visits, so
rather than being paid on a fee schedule, which is traditionally used today in
healthcare one is paid based upon the actual cost and determine on a pro-visit
basis and then as <_____> each year.
So Rural Health Clinic certification guarantees a better
In most cases, it does, while it has had less of an impact
in recent years with changes in fee schedules under Medicare program on the
Medicaid side. Most practices will realize, some were in the range of a 100%
greater reimbursement or for example, a typical reimbursement people service
was seen in Medicaid patient today in rural areas is about $30 to $40 and the
typical reimbursement under the Rural Health Clinics program for that same
patient would be about 72 dollars. So, essentially, almost double the
reimbursement for seeing Medicaid patients.
Can Rural Health Clinics offer services to cash paying or
Rural Health Clinics are actually like any office and often
are the first point of service in many rural areas and in many communities are
actually the only point of service and therefore they provide care to both
private, commercial, self-pay Medicare and Medicaid. Statistically, the Rural
Health Clinic will provide, about 60% of the service that they provide are
going to be Medicare or Medicaid and the balance is distributed then between
commercial and private payers and those with the self-pay as well.
And what type of services do they provide?
A typical Rural Health Clinics will provide the basic kinds
of primary care services. Some people use the definition in primary care or for
example in family practice from birth to death but, often it's going to be the
general types of primary care, preventive care that would be provided from the,
you know, newborn life cycle if you go to the senior and elderly life cycle and
in many cases, the difference between Rural Health Clinics, some may have
additional ancillary services that it can be really differ based upon the
community and the particular clinic.
And how are hospitals associated with the Rural Health
There are really 2 categories of Rural Health Clinics under
the Federal <_____>, one is called provider based and one is called
independent. The provider based is attached to hospital and as such has some
other opportunities or incentives when attached to the hospital, specifically
if the hospital is under 50 beds, there is no limitation on the amount of
reimbursement per visit on the Medicare side and the Medicaid reimbursement is
generally higher, for example in a provider based or hospital based Rural
Health Clinic, the average medicaid reimbursement is closer to $100.
Does a Rural Health Clinic have to be public or not for
One of the unique situations about or any characteristics of
the Rural Health Clinics program is that it offers any type of ownership
opportunity. Interestingly, 3% of the Rural Health Clinics that are about
depending on which number you look at, they are probably somewhere in the range
of 3400 Rural Health Clinics today, 3% of those are owned by PAs and/or nurse
practitioners. There are some that are owned by public such as health
department and there are some that are owned by hospitals, nursing homes,
private physicians, community groups that have gotten together and created not
for profit to own and operate and provide that kind of care in their
community. One of things that was part of the proposal when this program was
created is to allow the flexibility it would offer any opportunity in a rural
community. Having said that, I think it's also important to understand that
this still subject to state laws as it relates to the ownership and
<_____> practice as well.
What are the restrictions on PA and NP ownership?
Really in Rural Health Clinics there are none in the Rural
Health Clinic, it sounds like it can be owned and operated by Rural Health
Clinics or by PAs and nurse practitioners unless there is a restriction in the
state in terms of ownership as a practice. There is no restriction in terms of
their ownership, in difference and traditional medicare in this case, PA and
nurse practitioner can own the practice in its entirety and obtain numbers and
then contract with the physician for providing the direction and supervision
which is often the model that is seen in many rural communities where a
physician may be in a separate community, travel periodically to the clinic and
is contracted to provide the medical direction and the direction of the care in
What about the supervision requirements by a physician? How
does that work?
All medicare beneficiaries are required in the Medicare
program to be under the general direction of the physician, but its clearly an
opportunity for physicians in terms of extending care to these rural
communities to serve as a contracted service or they provide the medical
direction that requires that they are involved in the development of the
policies and procedures which govern the operation of the clinic including
safety, patient care policies, and that they must be as a minimum in the clinic
at least once every two weeks for a sufficient period of time to ensure quality
of care and to also see patients if necessary, unless the state law requires
something more rigid that is the absolute minimum requirement to the RHC
program requires and in most of the rural states, that is an acceptable
standard, the physician then have to be available by some formal radio or
telephone communication generally, but literally physically is able to travel
to the clinic periodicity schedule determined by the clinic and its staff or by
If you are just joining us, you are listening to the
clinician's roundtable on ReachMD XM 157, the channel for medical
professionals. I am Lisa D'Andrea and I am speaking with Ron Nelson, Physician
Assistant and President, CEO of Health Services Associates in Fremont,
Michigan. We are discussing physician assistants and nurse practitioners in
Ron, let's talk about the daily work in a Rural Health
Clinic. Do the providers feel isolated and how do they grow professionally
without the professional interaction?
Well, one of the issues we face currently is the same
problem with nurse practitioners and PAs that physicians face which is going to
the rural communities, being alone and having both the social and professional
isolation and so in order to recruit people to these communities, there is a
couple of areas that you can focus on, one trying to create professional
relationships in neighboring communities between the PA, nurse practitioner
and/or other colleagues and physicians that they don't feel the
professionalized relation and the feeling of being all alone. The second area,
I think in the social aspects are somewhat more problematic and that we see the
changing demographics of the graduates coming out of nurse practitioner and PA
training program are predominantly female and often in many cases are single females
that are at this point in their career now deciding about issues of starting
family and relationships and that social isolation is a difficult one. One of
the things that we recommend to clinics is to look at ways to provide some
respite for the provider to get away from the clinic to, you know, more urban
areas if that is their desire, building relationships that making clear to the
end of <_____>, you know, the need for them there and why you want them
there, but also be supportive in any ways to ensure that as much as we can we
take away some of the social isolation barriers that preclude people from
choosing that as an option to their practice.
What about the new practitioners? How can they provide
competing care when they have so little experience and they are alone?
Well, all Rural Health Clinics are not staffed independently
and alone by NPs and PAs, and I would tell you that probably its only 5% or
less of the typical PA, nurse practitioner graduates that are really at a level
that can function independently and alone in a practice such as the Rural
Health Clinic, so it really depends on the individual, their previous
healthcare experience, and where their level of skill is at. It usually takes
couple of years of experience for one is comfortable going out in a more
independent setting where they are delegated autonomy from the physician who
may be 30 to 40 miles away, as such is the case I practice in where my
supervising physician who resides about 40 miles away from where I am are
With increased cost of education and following the
physicians and the money and especially practice, how do you recruit a PA or an
NP to a Rural Health Center?
Well, I think that presents one of the most unique and
difficult challenges that we face in rural healthcare today, which is how we
will recruit and retain those individuals and I think one of the ways we do
that is we try and as much as we can train and socialize these individuals
during their training that it is okay to be in rural areas, which means
developing rural training opportunities, further exposed to practice situations
in rural areas so they can understand some of the positives of being in that
kind of environment and not that just hear about it and kind of develop a fear
that <_____> I go out there and be myself. The second area for
communities to develop models or programs to really encourage people to come to
their community whether its bonuses as a sign-on or mechanisms to ensure that
there is going to be a true respect via some kind of local <_____> for
ways to really get them away from the practice if you will and the opportunity
to enjoy being in the rural area, but to not feel necessarily socially and
professionally isolated. There are lots of strategies that are out there, that
are written about trying to help rural communities in many state offices of
rural health can really help with that approach.
All physician assistants and nurse practitioners have been
know to fill medical needs. Tell our audience about the impact that the Rural
Health Clinics have had on access to care on these areas.
Well, first of all, the Rural Health Clinics program is the
single largest program in the country today providing care to the rural
underserved communities and interestingly, it is staffed 50% of the time that
these clinics are staffed and must be staffed by PAs and nurse practitioners,
so they are making huge impact on