Long before their titles existed, nurses and other clinicians were filling gaps in care where physicians were scarce, particularly in rural areas. In this ACMPE Fellow paper, Shirley N. Craft, CPPM, FACMPE, traces how five advanced practice provider (APP) roles developed: nurse practitioners, physician assistants, certified nurse-midwives, certified registered nurse anesthetists and clinical nurse specialists.

The paper also covers:

• Why rural physician shortages persist and how states have tried to ease them
• APP education, board certification, scope of practice, collaborative practice agreements and prescribing authority
• Hospital credentialing, payer enrollment and Medicare reimbursement for APP services, including “incident to” billing
• The advantages and challenges of adding APPs, with results from the author’s survey of 11 APPs and 19 collaborating physicians in rural areas

Its attachments include a sample nurse practitioner scope of practice and a sample APP collaborating agreement from a pain management practice.

About ACMPE Fellowship papers

Fellowship (FACMPE) is the highest designation offered by the American College of Medical Practice Executives (ACMPE). Fellowship candidates wrote papers like this one to show command of a practice management topic through original research or a detailed business plan.

About this content

This paper was written in 2017 and has not been updated. State scope-of-practice laws, Medicare quality programs and APP workforce numbers have changed since then, so check figures, requirements and the sample agreements against current law and sources before using them. For more recent data, an August 2026 MGMA Stat poll found 51% of medical groups had added APP positions beyond backfills in the past 12 months.