Missouri is currently facing a shortage of primary care physicians. According to the Missouri Foundation for Health (2011), Missouri had only 116 primary care physicians per 100,000 individuals, compared to 128 physicians per 100,000 for the United States overall. Coupled with this is the fact that approximately 40% of Missouri’s population lives in health professional shortage areas (HPAS), which are areas where the population to practitioner ratio has been identified as greater than 3,500. According to Sears, et al. (2007), healthcare access is the most challenging problem facing our health system, especially in underserved and rural areas.

In the same article, the author commented that increasing shortage of primary care practitioners could be resolved with the help of Nurse Practitioners (NPs). In fact, NPs are more likely than physicians to provide care to those who are underprivileged and live in rural, under-served areas (Eibner, 2009).

State laws vary widely in the level of physician oversight required for nurse practitioners, with 19 states allowing NPs to practice independently, while others limit NPs’ authority to the diagnosis, treatment and prescription of medication without supervision. Currently under Missouri law, NPs must work under a so-called “Collaborative Practice Agreement,” House bill 564, which requires them to work with a supervising doctor before providing health care services within the nurse’s certified level of training. Prior to the 1975 amendments to the Nurse Practice Act, all nurses in Missouri were expected to work under the direct supervision of a physician. In response to changes in medical care delivery and lack of primary care physicians, the legislature modified the 1975 Act to broaden the authority of nurses. In 1993, the Missouri legislature passed a health care reform bill, which dealt with the extent to which nurses could see patients and provide treatment without the direct physician supervision – what Missouri calls collaborative practice between physicians and nurses. The regulation became effective on June 30 in 1996 (Board of Nursing, 2014).

The integrated use of NPs and physicians together has positively affected the health care system. In the retrospective study on chronic disease management care to evaluate the effect of collaborative care model by Lawson, et al. (2012), the authors indicated that patients receiving chronic disease management who receive care through a collaborative practice where a NP is part of the team received better care management that those managed by physicians alone.

However, despite of areas of positive result through the use of the collaborative care model, “Collaborative Practice Agreement” seems to offer a reduced level of quality of health care for patients by preventing NP’s to maintain independent practices as the law delimits NP’s geographic working areas, methods of treatment, review of services, and drug dispensing pursuant to prescription (Board of Nursing, 2014). Restricting patient access to NP independent practice is restricting the access to health care in many ways. For instance, in rural Missouri, if one physician is present, the area may only have 3 NPs because Missouri Statute 334 defines a 3:1 ratio of NP to physician (Office of State Court Administrator, 2014).

The Collaborative Practice also limits access to health care as a result of potential liability. According to (4) (E) of rule, the physician must establish a system to review the practice of the NP at least once every 2 weeks (Board of Nursing, 2014). Phillips, et al. (2002) found that some physicians wouldn’t sign an agreement of this nature because they believed they would be held liable for the NP’s practice if they signed such an agreement. As a result, NPs are having difficulty locating physicians who are willing to enter into a collaborative prescribing agreement. Because of this, NPs who are willing to practice in underserved areas as well as urban areas are not able to establish practices. It is for these reasons that Missouri should remove this mandated “Collaborative Practice Agreement.”