Missouri forces nurse practitioners to buy permission to work—from doctors

Marcy Markes has spent more than 30 years caring for patients across Missouri. She has worked in intensive care, management, and small-town clinics. A licensed family nurse practitioner with multiple degrees from the University of Missouri, she’s owned and operated Columbia Allergy and Asthma Specialists since 2003, providing lifesaving asthma, allergy, and immunotherapy services. Her clinics also mentor nursing and medical students, training the next generation of healthcare professionals.

But in Missouri, hard work, skill, and education aren’t enough. State law mandates that nurse practitioners who want to treat patients outside a hospital setting must obtain a “collaborative practice agreement” (CPA) with a physician. Put simply, NPs must pay an expensive babysitter whose permission slip lets them do the very work they’re already trained and licensed to do. An NP can’t even order a routine lab test or prescribe generic medication without it.

Contrary to advocates’ claims, CPAs do nothing to improve patient safety or reduce provider liability. Most states don’t require them and patients in those states are the better for it. What CPAs do instead is give physicians government-backed control over nurse practitioners’ livelihoods, and, with no cap on fees, the power to charge whatever they want to exercise that control.

Marcy pays over $50,000 a year for her CPA license. At that rate, a physician supervising the legal maximum of six nurse practitioners could rake in more $300,000 annually—for babysitting professionals.

The consequences for working without one of these agreements are severe: license censure, suspension, or revocation by the Missouri Board of Nursing, enforcement actions by the Board of Registration for the Healing Arts, and criminal prosecution by the state attorney general. Practicing medicine without a license is a felony punishable by up to seven years in prison and fines of $10,000 for each patient seen by the NP.

Missouri is one of just 11 states with such restrictive rules, and its laws are among the harshest. It’s especially concerning that 80 percent of the state is considered a “physician desert,” where residents have little or no primary care access. Yet the law allows physicians to decide the trajectory of a nurse practitioner’s career and, in turn, the availability of care.

The Missouri Constitution promises every person “the enjoyment of the gains of their own industry.” But the CPA scheme strips that right from nurse practitioners like Marcy, forcing them to pay for permission to do the very work they are licensed to do. The law’s irrational, protectionist constraints on an entire profession also violate the state and federal constitutions’ due process protections, harming providers and the patients who need them by imposing arbitrary and irrational burdens on NPs.

With Pacific Legal Foundation’s free representation, Marcy is taking Missouri to court. She’s fighting to strike down the CPA law so that she, as well as her fellow and future nurse practitioners, can practice to the full extent of their qualifications and experience without government-mandated physician middlemen.

Missouri isn’t alone in blocking access to qualified professionals who simply want to serve their communities. A report released by PLF compares CPA laws and regulations across the 50 states and shows how they stifle entrepreneurship, raise healthcare costs, and limit care options in the states that require full CPAs or similar arrangements. PLF is working to end these unconstitutional restrictions in Missouri and everywhere else they limit opportunities for independent practice and stand between patients and providers.