Shannon Eaton is a nurse practitioner providing mental health care in a gym office in south Springfield. However, she’s not treating Missouri patients. She’s practicing through telehealth in the state of Washington and has been for two years.
She explains, “my income is more, much more than what I was making here. It really has helped me achieve a better life-work balance, but I’m still kind of left with — I have friends and family here that need good providers.”
Also for the past two years, Eaton has been trying to open her own mental health clinic in Springfield. She said running her own practice in Washington is easier than in Missouri because of state policy differences. In order for nurse practitioners to provide care in Missouri, they must have a collaborative practice arrangement with a physician.
Finding one as an independent nurse practitioner is difficult," Eaton said. "Even if I found a young family practice physician, he might be starting his own clinic and he might want to hire his own NPs. I don’t want that. I want my own practice.”
What the law requires
A collaborative practice arrangement is a legal document and agreement between a physician and a nurse practitioner. It’s required by Missouri law for nurse practitioners to prescribe medicines and treat and diagnose health problems in any setting—like an independent clinic or a health system.
According to the law, physicians are required to meet with the nurse practitioner once every two weeks to go over charts. However, not all charts are required to be reviewed. If the nurse practitioner is prescribing controlled substances, the physician reviews a minimum of 20% of the charts. If controlled substances aren’t prescribed, the minimum is 10%.
“I was frustrated though, because I couldn’t find a collaborating physician that...wasn’t charging what I would consider excessive amounts," says Eaton.
The law doesn’t regulate how much a physician charges. Eaton said the rates she sees are about $1,500 to $2,000 a month. KSMU spoke with multiple former and practicing nurse practitioners that gave the same estimate. Additionally, a physician can collaborate with up to six nurse practitioners in Missouri.
Eaton said she doesn’t pretend to be a physician. But she is an advocate for nurse practitioners and the care they provide.
“I do have an affinity for nurse practitioners. We're trained differently. We're not physicians. We were not trained in the medical model. We're trained in the nursing model, and we provide really holistic care," said Eaton. "And that’s not to say there’s not wonderful physicians, but I really think nurse practitioners do a great job.”
The difference between physicians and NPs comes down to one thing: Education. Physicians earn a bachelor's degree, complete a four-year medical degree and have a three to seven-year residency period, depending on the field they want to enter. Nurse practitioners earn a Bachelor’s in Nursing and complete a Masters of Advanced Nursing Practice, which includes on-site clinical hours. Some can also complete a Doctor of Nursing Practice.
Advocacy
Missouri APRN Full Practice Authority is an advocacy group that started two years ago. JoAnn Franklin, the group's treasurer and an NP, said collaborative arrangements are basically rituals.
“If they review your chart in two weeks and I give you an antibiotic for 10 days, by the time they review your chart in 14 days, there’s not impact on health care," says Franklin. “Our whole goal is to improve access and get rid of the health care deserts in Missouri because almost every single county is a health professional shortage area for primary care.”
Data by the Center for Health Policy through Mizzou backs that up.
“I think freeing up advanced practice registered nurses in Missouri is going to have a positive impact on health care throughout the state," Franklin said. "I think there is so many people out there that could do good work and that these collaborative arrangements, fees, expenses, are just excessive — especially since it doesn’t really benefit care.”
The group filed an initiative petition for full practice authority but failed to get enough signatures by the May 5th deadline, so it won't be on the ballot this November. However, Franklin says the group is going to continue to advocate.
Types of policies
Twenty-seven states allow nurse practitioners to practice without a collaborative practice agreement with a physician. Iowa and Kansas have these types of policies. There are only 11 states, like Missouri, with the most restrictive policies.
The other policy is in the middle: Transition to full practice. After a certain amount of collaborating hours with a physician, nurse practitioners can practice without a collaborative arrangement. Arkansas and Illinois are transition to practice states.
House Bill 1773 would make Missouri a transition to practice state, with a 2,000-hour requirement. It's likely the bill won't move out of the house as the general assembly legislative session ends May 17.
A public hearing on Feb. 7 of the bill showed strong support and opposition. George Hruza spoke in strong opposition on behalf of the Missouri State Medical Association, an advocacy group for physicians. "You want to be able to have that collaboration so that the nurse practitioner is able to have someone that she can rely on if there is a problem or if there is a difficult, unusual case,” he said.
Hruza also said in opposition that NPs don’t have enough education or training for a transition to practice policy. In response to the health care shortage, he said there are other ways to address it, such as increased residency expansion sites for medical doctors, or increasing student loan forgiveness incentives for health care professionals working in rural or shortage areas.
In response to the educational differences, Franklin and Eaton both said they would never practice outside of their scope and would make referrals when they needed to.
KSMU contacted the Missouri State Medical Association multiple times for an interview, but never received a reply.
