Nurse Practitioner, Forced to Pay $50K Physician Oversight Fee to Run Clinic, Sues State

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A licensed family nurse practitioner with over 30 years of experience, Marcy Markes, is fighting back against Missouri’s law that forces nurse practitioners (NPs) to pay physicians for permission to practice in non-hospital settings. On August 20, 2025, she filed a lawsuit challenging the state’s collaborative practice agreement—and the hefty costs and legal burdens it imposes—arguing it violates her constitutional rights under both state and federal law.

The Challenge: Costly and Constrictive Law

Missouri mandates that NPs maintain a Collaborative Practice Agreement (CPA) with a physician to deliver even routine care. Marcy pays upwards of $50,000 annually for this so-called "permission slip."

Markes is a highly experienced Family Nurse Practitioner (FNP-BC) with decades of clinical and leadership roles in acute care and allergy/immunology services. She earned both her BSN and MSN from the University of Missouri’s Sinclair School of Nursing and holds national certification from the ANCC. Her career spans ICU, cardiac, thoracic, and research settings, and her clinic, Columbia Allergy & Asthma Specialists sees 6,500 patients annually.

From the complaint: “By law, Ms. Markes must contract with a physician to see patients at her clinic and provide the care that she is specifically licensed to deliver. Because of this mandate, Ms. Markes must pay a physician $52,800 per year—an artificial cost imposed by Missouri law—just to engage in the very work she is uniquely qualified to perform.”

Missouri is among only 11 states imposing such restrictive CPA mandates, despite 80% of its counties being physician deserts—areas with little or no access to primary care. The law allows physicians to control nurse practitioners’ livelihoods—and charge unlimited fees for minimal oversight, exacerbating healthcare shortages and limiting affordable care.

Legal Arguments: Constitutional Rights at Stake

Markes’ complaint asserts that Missouri’s CPA requirement:

• Violates the Gains of Industry Clause in the Missouri Constitution by denying her the right to enjoy the fruits of her labor without paying for bureaucratic "permission."
• Breaches both state and federal Due Process rights, as it arbitrarily restricts her profession and imposes burdens unrelated to patient safety.

Through her pro bono legal team at Pacific Legal Foundation, Markes argues the law serves no public safety purpose and instead protects economic interests and stifles care access.

Markes’ Attorney, Donna Matias, summed it up: “Nurse practitioners are exceptionally trained, licensed healthcare providers who shouldn’t need to pay a doctor tens of thousands of dollars just for permission to treat patients. This protectionist scheme strips away Marcy’s constitutional rights while worsening Missouri’s healthcare crisis.”

What’s at Stake for Missouri’s Patients and Providers

A victory in Marcy Markes v. Andrew Bailey could:

• Empower NPs to practice independently in underserved regions.
• Lower healthcare costs and improve access.
• Provide constitutional protection for professional autonomy.

For nurse practitioners across the country, this lawsuit shows the real challenges created by collaborative practice laws. It’s a reminder of why pushing back against restrictive rules matters—not just for professional freedom, but for patients’ access to care. The outcome of this Columbia case could influence how NPs practice in Missouri and beyond.

AG Andrew Bailey has not publicly addressed this court case, but he did recently announce his resignation in order to serve as Co-Deputy Director of the FBI.

Nurse.org will continue to update this article as more information becomes available.

 

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