Patients deserve better: Missouri NP takes stand against barriers to healthcare
Finding a great healthcare provider is like winning the lottery. And Nurse Practitioner (NP) Marcy Markes’ patients have hit the jackpot. Since 2003, Marcy has owned and operated the Columbia Allergy and Asthma Specialists clinic in Columbia, Missouri, where she provides vital treatment to about 6,500 grateful patients a year.
As a true testament to her abilities, one patient, whose quality of life greatly improved after Marcy began treating his horrible asthma six years ago, has even been willing to drive several hours to see her. “He actually is moving to Montana to work on a dude ranch, but he’s going to keep coming back to me. He told me, ‘I don’t care. You tell me when to be here and I’ll be here. I’m not going to anybody else,’” Marcy said.
He isn’t the only patient who travels a great distance for his appointments. Another patient makes annual trips from New York, not because flights are fun, but because Marcy is just that good at what she does.
For Marcy, building these types of relationships with her patients is essential. Too often, patients find themselves frustrated because they don’t feel heard by their providers. But that’s not how Marcy does things in her clinic.
Marcy played the role of family nurturer growing up and always knew she wanted to be a nurse. Her brothers would probably lovingly describe her as “bossy,” but it was the kind of bossy that kept the family together when her single mother was working. She met her husband in the same small town where she grew up. They’ve been together since the late ’80s, now stealing quiet hours on a beach in St. John when they can.
Marcy earned a B.S. degree in nursing and then a graduate degree as a family nurse practitioner. She gained experience working in the ICU at a VA facility and then got into clinical research, where she found her home in the allergy and asthma world.
Yet, despite over 30 years of experience and multiple degrees, Missouri state law forbids Marcy from seeing patients unless she pays to be under the supervision of a physician.
Collaborative practice agreements
Missouri is one of 11 states to require nurse practitioners to obtain what are called collaborative practice agreements (CPA) with physicians before they are allowed to do their job. CPAs are belittling, to say the least, as they force qualified healthcare professionals like Marcy to pay a glorified babysitter to do a job they are already qualified to do. CPA requirements are so severe that an NP can’t even order typical lab tests or even prescribe generic medication to their patients without a doctor’s signature.
Without a signed CPA, an NP risks discipline from the Board of Nursing, accusations of “unauthorized practice of medicine,” and even felony charges. The law layers on operational strings: chart-review quotas, on-site presence requirements, and a month of continuous on-site supervision before an NP may work without the physician in the room.
Finding a collaborator is an ordeal in itself. making it difficult to build a relationship of mutual respect. Plus, state laws limit each supervising physician to six NPs and PAs, so even if an NP finds a doctor they like, there may not be room to take them on as a collaborator. And if the collaborating physician quits, retires, or moves, an NP may suddenly find themselves entirely unable to fulfill their obligations to their patients.
Adding to the burden of finding a physician to work with, the CPAs also place extreme financial burdens on NPs. For years, Marcy has paid a physician nearly $4,500 each month to remain “paper legal.” That’s over $50,000 a year for nominal oversight. This money would be better spent paying the salary of another provider, expanding clinic hours, or lowering patient costs. Instead, the money is siphoned into a mandated permission slip.
Meanwhile, supervising physicians have the potential to rake in vast sums of money annually, while the NPs are doing the real work for their patients.
The CPA requirements don’t just keep NPs on a legal leash; they also put them in a vulnerable position with physicians who might take advantage of the situation. Fortunately, Marcy eventually found a collaborating physician with whom she has a great relationship.
Creating barriers to healthcare
While those responsible for CPA laws allege their purpose is protecting the health and safety of patients, there is no evidence to back up this claim, especially in Missouri where the healthcare system is already struggling to meet demand.
Eighty percent of the state is considered a “physician desert,” where residents have little or no primary care access. Even in Columbia—a university health hub—new primary care appointments can mean months of waiting. People drive for hours for routine care. Some don’t have reliable internet, which makes telehealth better in theory than in practice. Meanwhile, an NP who could open shop in a town that desperately needs her is stuck scouring for a collaborator whose quota isn’t already full, and who won’t jack up the price mid-contract—which is always on the table because Missouri law doesn’t cap the amount a doctor can charge an NP.
Missouri policymakers’ claims of health and safety fall flat, as other states prove. A growing majority of states allow NPs to practice independently. Research—including PLF’s recent report—shows that CPAs don’t improve patient outcomes, but they do raise costs and suppress competition, particularly in rural and underserved communities. As it turns out, not only does the sky not fall, but removing CPAs actually expands access.
Most perplexing of all: Missouri policymakers already know this to be the case, even if they won’t say it out loud. During the COVID-19 pandemic, the state temporarily waived key CPA rules. If those restrictions were truly indispensable for safety, you wouldn’t lift them during a global health crisis. Yet care continued—and Missourians benefited.
Marcy is not one to stay quiet when both her patients and her fellow NPs deserve better.
Together with Pacific Legal Foundation, Marcy is challenging Missouri’s CPA requirements in court. The Missouri Constitution’s Gains of Industry Clause protects the right to enjoy the fruits of one’s labor. Forcing Marcy to surrender tens of thousands of dollars a year to a private party—just to keep practicing the profession she lawfully trained for—violates that right. Preventing providers from using the full extent of their qualifications and experience also violates the state and federal constitutions’ due process protections.
Pacific Legal Foundation’s fight to free qualified professionals from the regulatory cages that keep them from serving their communities is not limited to Missouri alone. Our recent report does a deep dive into CPA laws across the country to show how they stifle entrepreneurship, raise healthcare costs, and limit care options in the states that require full CPAs or similar arrangements.
Patients deserve access to quality care from providers who listen to them and understand their needs. And top-notch, qualified providers have a right to serve their patients and secure their own financial livelihoods at the same time.
For Marcy, her fight is focused on her patients. “It’s not about me,” she says. It’s about letting Missourians choose their healer—and letting a nurse keep the gains of her own industry.
