Collaborative Agreements: Outdated and Unjust

Across the country, Nurse Practitioners provide quality and effective healthcare to millions of patients.

We are highly educated, highly trained, and fully licensed professionals delivering a range of services, from primary care to specialty care.

We have done so for many years, and research shows that NP delivered care is effective. And in some cases, NP care has been shown to be more effective than non-NP-provided care.

Yet, in a handful of states, outdated laws require us to enter into collaborative agreements with physicians so that we can practice independently, to the full extent of our education and license.

While these agreements were initially intended to ensure oversight, they now seem to be little more than financial gatekeeping.

For the ‘privilege’ of doing the very work we’re lawfully licensed to perform, physicians can charge NPs tens of thousands of dollars each year.

And some do just that…

The result?

Patients lose access to care, NPs lose autonomy, and the healthcare system as a whole becomes even more strained.

Paying for Permission to Practice!

A Nurse Practitioner in Columbia, Missouri, has filed a lawsuit challenging Missouri’s collaborative practice agreement rule.

With over 30 years of experience as a Nurse Practitioner, Marcy Markes, MSN, APRN, FNP-BC, AE-C, is still required to maintain a collaborative agreement to practice independently.

This little collaborative agreement, one might say a remnant from the past, is costing her over $50,000 a year!

The majority of physicians don’t charge such ridiculous fees for collaborative agreements, but apparently, some do.

I can’t speak for you, but to me, this is an outrageous and exorbitant amount of money to pay for something you are legally entitled and qualified to do.  

This is money she is required to pay to a physician for minimal, if any, oversight.

Fair? NO…  

Pathetic? YES!  

Legal…?

The Case

Ms. Markes is represented by the Pacific Legal Foundation, a nonprofit law firm that defends Americans against government overreach.

Ms. Markes argues that Missouri’s requirement violates her constitutional rights and worsens the state’s already dire healthcare shortage.

You can read more about her case here.

Missouri is one of a handful of states that continue to enforce these restrictive collaborative practice laws, with devastating impact.

The state of Missouri has widespread shortage areas and is considered a medical desert, with limited access to primary care.

But rather than enabling NPs to help fill the gap, the law gives physicians unchecked power to control NP careers and charge unlimited fees for collaboration.

For patients, this translates to longer wait times, fewer treatment options, and higher costs.

For NPs, it means limited independence, financial strain, and barriers to serving their communities.

This Case Matters to All NPs

This lawsuit, Marcy Markes v. Andrew Bailey, is about more than one NP and her fight for justice.

It represents a pivotal moment in the nationwide fight for NP independence.

A victory would free Missouri’s NPs from burdensome and unnecessary collaborative agreements and payments, and it could also pave the way for reform in other restrictive states.

If successful, the case would likely expand healthcare access across Missouri, especially in rural and underserved areas where NPs may be the only providers. And it would set an important precedent to end prioritizing outdated laws (and profits) over patient care.

The Big Picture

Why are collaborative agreements still on the books?

While I have a theory, I know they don’t make healthcare safer. Nor do they improve patient outcomes.

However, they create artificial barriers that limit patient access and penalize qualified professionals.

Nurse practitioners in full-practice states already deliver exceptional care without physician oversight.

And there is no evidence that such costly agreements protect patients. However, the evidence suggests that they exacerbate shortages and increase healthcare costs.

It Takes a Village…

Affecting change and changing laws is a slow and expensive process.

This type of change requires the work and support of the entire NP community.

I encourage you to support your state and national organizations; get involved and do whatever you can to help advance our profession.

At a minimum, join your professional state and national organizations.

And… stand up for what you believe and know is right!  

The Missouri case is about fairness, access, and professional respect. While the state may be different, the cause rarely changes…

It’s about ensuring that Nurse Practitioners can do the work they are trained, licensed, and committed to doing… without having to pay to get permission to do the work.

Patients deserve better.

And we, as NPs, deserve better, too.

PS: To help support this case, you can donate to the Pacific Legal Foundation.

Please share your thoughts… let us know what you think.

By Johanna Hofmann, MBA, MAc., EAMP; regular contributor to the NPBusiness blog and author of “Smart Business Planning for Clinicians.”