A licensed family nurse practitioner has filed a lawsuit challenging a Missouri law that forces NPs to pay physicians for permission to practice in nonhospital settings.
According to court documents, Marcy Markes owns and operates Columbia (Mo.) Allergy & Asthma Specialists. Her lawsuit, filed Aug. 21, specifically targets a legal requirement that NPs maintain a collaborative practice agreement with a physician to deliver care. Ms. Markes pays more than $50,000 annually for this permission.
Missouri is one of 11 states with a CPA mandate for NPs. In the lawsuit, Ms. Markes argues that NPs are not burdened by this oversight standard across most of the country, emphasizing that NPs are “highly trained professionals who can safely and effectively deliver primary and specialty care, including diagnosing illnesses, prescribing medications and managing chronic conditions.”
Her lawsuit also highlights that while NPs must have a CPA to practice medicine outside of a hospital setting, there is not the same requirement for physicians. Without an agreement, NP owners could face penalties from the Missouri Boards of Nursing and Registration for the Healing Arts, or potentially a class D felony, the Columbia Daily Tribune reported Aug. 25.
Physicians are also permitted to collaborate with up to six NPs, limiting the number of available collaborators and driving up costs for NPs to practice, particularly in rural areas. This is notable given that 80% of Missouri’s counties are denoted as “physician deserts,” according to HHS.
Ms. Markes also argues that the requirements under a CPA are loosely enforced and are not required to be filed with the state. They do require NPs to share 10% of patient charts with a collaborating physician for review and 20% of charts if the NP prescribes medication. For those in specialized fields, the collaborating physician must be at the clinic once every two weeks. NPs also have a one-month continuous oversight requirement before they can practice on their own, per CPA rules.
“These mandates force NPs to subordinate their practice efficiency and autonomy to physicians’ availability, resulting in operational disruptions and delayed patient care,” Ms. Markes’ attorney argues in the complaint. “There is no mechanism to ensure that the collaborating physician actually performs chart reviews or supervisory duties.”
The constitutionality of the CPA mandate is also questioned in the lawsuit, in which Ms. Markes argues that the CPA rule prevents her from “enjoyment of the gains of [her] own industry,” under the Missouri Constitutions’ gains-of-industry clause. She also claims it violates Missouri’s due process clause because the “burdensome agreements … provide no demonstrable benefit to the health, safety and welfare of Missourians.” She maintains a similar argument with regard to the federal Constitution’s own due process clause, claiming that the CPA limits her ability to fully practice, despite her qualifications.
