$50K Permission Slip: The Controversial Law Keeping NPs Dependent
You asked and we listened. The national debate over nurse practitioner (NP) independence is heating up again, and it’s not just Missouri at the center. While Missouri has drawn headlines recently for a federal lawsuit challenging its collaborative practice agreement (CPA) requirements, many NPs across the country face similar hurdles to practicing at the top of their license.
On August 21, 2025, veteran nurse practitioner Marcy Markes, who runs Columbia Allergy & Asthma Specialists, filed suit challenging Missouri’s CPA mandate as unconstitutional. Her case argues that the requirement undermines both professional autonomy for NPs and patient access to care in one of the most underserved states in the country.
The Cost of Missouri’s CPA Law
Missouri requires NPs to maintain a formal CPA with a physician in order to provide most outpatient services. For many, this is not about meaningful supervision but about a costly signature. Physicians can oversee up to six NPs at a time, reviewing just 10–20% of charts and making occasional visits—yet NPs must pay tens of thousands of dollars for this arrangement.
Across several states, this dynamic has drawn criticism as a possible predatory practice. Because there are no standardized limits on fees, physicians are free to charge whatever they choose, often creating contracts worth tens of thousands of dollars annually. In many cases, NPs operate their clinics independently, handling patient care, administration, and overhead, while paying collaborators who may have no direct involvement in the practice. Critics argue this arrangement exploits nurse practitioners by possibly siphoning income from their work, creating financial dependency, and allowing physicians to profit simply by lending their license.
For NPs, this means working under conditions where their compensation can be comparable to that of registered nurses, despite advanced training and independent practice responsibilities. For patients, the downstream effects include increased healthcare costs, reduced availability of NP-led clinics, and longer wait times—especially in Missouri, where 80% of counties are considered medically underserved areas or “physician deserts.”
Constitutional Arguments
Markes, with the support of the Pacific Legal Foundation, contends the CPA rule violates the Missouri Constitution’s “gains of industry” clause, which protects the right to earn a living without being forced to pay third parties. The lawsuit also raises due process concerns at both the state and federal levels, pointing out that physicians themselves face no such restrictions, and that most other states allow NPs to practice independently without compromising patient safety.
The lawsuit further argues that CPAs are not backed by evidence showing they improve outcomes. Instead, they serve to protect economic interests, limit competition, and allow physicians to leverage their role in a way that financially disadvantages NPs without providing meaningful oversight.
Are Other States Facing the Same Problem?
Missouri is not alone. Nurse practitioners in several other states face similar challenges:
- California: Two psychiatric NPs have sued, arguing that the state’s nursing board is undermining AB 890—a law intended to grant independence—by continuing to restrict practice authority.
- Nebraska: In Swanson v. Hilgers, a certified nurse-midwife challenged restrictive supervision laws around home births, citing constitutional violations.
- Michigan: Lawmakers have introduced bills that would grant NPs full practice authority upon graduation, eliminating mandatory physician contracts.
- Nationwide: Roughly half of U.S. states still require some form of physician supervision or CPA. In many, NPs report delays in opening clinics, higher operating costs, and ongoing financial strain due to oversight fees.
In contrast, more than 20 states have granted full practice authority, allowing NPs to practice independently without physician contracts. Research shows no compromise in safety or patient outcomes under these models, and advocates argue these states demonstrate how outdated CPAs have become.
National Implications
This case is about more than one NP in Missouri. It reflects a broader movement across the country where some nurse practitioners and healthcare advocates are calling CPAs outdated, costly, and in some cases predatory. Dozens of studies and policy statements, including those from the National Academy of Medicine, support full practice authority for NPs, citing benefits like reduced costs, better patient access, and outcomes equal to or better than physician-led care.
While some physician groups defend CPAs as ensuring quality and teamwork, many in nursing view them as unnecessary barriers that add costs, create dependency, and allow physicians to take advantage of the system by charging high fees without providing direct oversight.
If successful, Markes’ lawsuit (Marcy Markes v. Andrew Bailey) could set a precedent not only for Missouri but for states nationwide—reshaping the future of nurse practitioner practice and expanding access to care for thousands of patients in medically underserved areas.
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