Nurse practitioners can help fill Missouri’s provider gap
For many Missourians, access to healthcare is out of reach. Eighty percent of the state is considered a healthcare desert, with too few providers to meet the needs of local residents. Missouri ranks among the worst in the nation for primary care shortages, and in some rural counties, patients must drive 30 to 45 minutes just to reach the nearest hospital.
Yet instead of empowering more providers, Missouri law exacerbates this crisis by tying the hands of nurse practitioners (NPs), whose advanced medical training and scope of practice uniquely position them to help expand healthcare access in communities that need it the most. State law forces these highly qualified professionals to practice under restrictive collaborative practice agreements (CPA) with physicians, preventing them from working to the full extent of their training and limiting their ability to alleviate Missouri’s healthcare provider shortage.
Few people understand this problem better than NP Marcy Markes, who has spent more than 30 years caring for patients across Missouri. Since 2003, she has owned and operated an allergy and asthma clinic that provides lifesaving services while also mentoring nursing and medical students. But despite her training, experience, and the critical role her clinic plays in providing healthcare access, Missouri law requires Marcy to maintain a CPA, essentially paying a physician tens of thousands of dollars a year just to keep her clinic open.
The cost of collaboration
A CPA is a formal agreement requiring a physician to oversee an NP’s work. Supporters argue that CPAs protect patient safety. In reality, they undermine safety by restricting access to care and making it harder for patients to see a provider at all.
NPs like Marcy are already licensed, certified, and accountable to professional boards. But under Missouri law, an NP can’t order routine lab work, prescribe a common medication, run a small-town clinic, or otherwise practice to the full extent of their training without paying a physician collaborator.
These agreements are costly. Missouri law doesn’t cap the fees doctors can charge, which allows physicians to set their own rates. And because each physician can collaborate with only six providers, the demand for limited CPAs drives prices even higher. A 2023 survey by the Missouri Nurses Association found physician collaboration fees as high as $52,000 per year. Marcy herself pays over $50,000 annually, which is money that could otherwise fund patient care. A Missouri physician collaborating with the maximum six providers can collect more than $300,000 annually in fees, without meaningfully overseeing patient care.
While state law requires that physicians review at least 10% of an NP’s charts annually (20% if controlled substances are prescribed) and visit the clinic every two weeks if the NP is treating acute or chronically ill patients, many NPs report receiving little to no supervision. What CPAs really do is create an expensive barrier to entry for entrepreneurial NPs aiming to expand healthcare access and fill Missouri’s provider gap.
Barriers to care
The consequences of Missouri’s restrictive CPA law are felt across the state. Missouri had 336 federally designated primary care shortage areas as of April 2025, according to the U.S. Health Resources and Services Administration’s Health Professional Shortage Area (HPSA) criteria, ranking among the highest in the nation for primary care shortages. In contrast, neighboring Kansas had only 160 primary care HPSAs, and Nebraska had only 131. More than 1.8 million Missourians live in these shortage areas, and more than 11% of residents live in counties without a hospital at all.
Missouri’s burdensome CPA requirements make the shortage worse. An NP must find a collaborating physician within 75 miles, an impossible hurdle in many rural regions. On top of the distance requirement, the six-provider limit means that even when physicians are available, collaboration slots are often full or prohibitively expensive. Moreover, NPs who enter into a new CPA, regardless of experience, must spend a month under the physician’s direct supervision before they can serve a new community, delaying them from providing healthcare in areas that need it most.
A better way
Most states don’t shackle NPs with burdensome CPA requirements. PLF research into CPA requirements found that 35 states and the District of Columbia allow NPs to practice independently or have a limited CPA framework with a path to independent practice. Research has shown that patients in these states have greater access to healthcare without any decrease in quality or safety.
Missouri should be making it easier—not harder—for NPs like Marcy to step in and fill the state’s provider gaps. Research has shown that NPs are more likely to practice in primary care shortage areas in states without CPAs. In nearby Nebraska, for example, the NP workforce increased in 20 primary care shortage areas within five years after lawmakers adopted a path to independent practice for NPs. Similarly, after Nevada implemented independent practice for nurse practitioners in 2013, the state saw a 33% increase in NPs by 2016, with many relocating from other states. Eliminating CPAs in Missouri could yield similar results by attracting new practitioners and expanding access to underserved communities.
Collaborative practice agreements don’t protect patients. By giving physicians control over whether NPs can practice, CPAs drive up costs, limit competition, and worsen Missouri’s healthcare shortage.
PLF is representing Marcy in an effort to end CPA restrictions in Missouri. Policymakers should free NPs like Marcy to do what they are trained and licensed to do: provide safe, high-quality care to the patients who need it most.
