Reps. Axne, Smith Introduce Bipartisan Rural Hospital Relief Bill

June 25, 2019
Press Release
Legislation would delay enforcement of burdensome government regulations on small rural hospitals

WASHINGTON – Today, U.S. Reps. Cindy Axne (D-IA-03) and Adrian Smith (R-NE-03) introduced bipartisan legislation to provide relief to rural hospitals by delaying enforcement of burdensome regulations that limit the ability of Critical Access Hospitals (CAHs), or rural hospitals, to provide quality care. The legislation postpones implementation of “direct supervision” – or the requirement that a physician or nonphysician practitioner be physically present – for outpatient therapeutic services at rural hospitals until 2021.

“I’ve heard from dozens of rural health care providers across Iowa’s Third District who consistently tell me that staffing shortages continue to be a top concern. Insufficient staff available for direct supervision can limit the type of care Iowans living in our rural communities can receive,” said Rep. Axne. “We need to address staffing shortages in rural areas, but in the meantime, we need to make sure that regulations aren’t overly burdensome for rural hospitals.”

“Burdensome regulations like arbitrary physician supervision requirements do not account for the unique challenges faced by rural providers and place a great strain on them. Rural Americans deserve ready access to quality care, and I am pleased this legislation will extend longstanding relief which is necessary to ensuring rural providers can meet the needs of their patients,” said Rep. Smith.  

Given that rural hospitals have difficulties recruiting physicians to practice in rural areas, the direct supervision requirement can be a limitation on the type of care available to rural Iowans. This legislation would delay enforcement of this rule until 2021, giving CAHs and rural hospitals more time to comply as Congress works to improve staffing shortages at rural hospitals.


In 2009, the Centers for Medicare and Medicaid Services (CMS) payment rulemaking process required Medicare hospitals implement “direct supervision” for outpatient therapeutic services, which means a physician or nonphysician practitioner must be physically present, or within an immediate distance. Rural hospitals and CAHs expressed concerns to CMS regarding insufficient staff available to comply with direct supervision requirements, especially for specialty services.

In response to these concerns, CMS delayed the requirements until 2013. Congress also extended this delayed enforcement from 2013-2016. CMS has continued nonenforcement in 2018 and 2019. This legislation would again delay the direct supervision enforcement statutorily until 2021.