Stop, Collaborate, and Listen: Missouri Requirements Regarding Collaboration With and Supervision of Advance Practice Nurses

It is estimated that by 2034, the United States will experience a shortage of up to 124,000 physicians, including a shortage of primary care physicians ranging from 17,800 and 48,000.¹ Advance practice nurses (APRNs) can play a significant role in addressing the shortage of primary care physicians, but APRNs cannot practice without collaborating with a licensed physician in Missouri. This article will discuss the specific statutes and regulations that govern those collaborative arrangements and provide some recommended practices for physicians who engage in collaborative arrangements with APRNs based on some illustrative cases.

Stop: Physician Shortage and APRNs Role

The supply of primary care physicians has been dwindling. It was reported that more than one third of the US counties has a primary care supply problem.² Missouri is no different. “As much as 80% of Missouri needs a doctor. The Health Professional Shortage Area (HPSA) arm of the U.S. Department of Health and Human Services estimates it would take about 600 physicians—more than the entirety of the Kansas City University Class of 2023—to fill that gap.”³ The University of Missouri published a map which illustrates that most Missouri counties in 2021 had a primary care provider shortage where the demand exceeded the supply (Figure 1).⁴

APRNs⁵ can play a vital role in addressing the primary care physician shortage by providing accessible and high-quality healthcare services. APRNs are registered nurses (RNs) who have completed advanced education and training in a specific area of nursing practice. In addition to their RN license, APRNs in Missouri must also hold a certification in their advanced practice role. There are four recognized advanced practice roles in Missouri: Certified Nurse Practitioner (CNP), Certified Registered Nurse Anesthetist (CRNA), Certified Nurse-Midwife (CNM), and Certified Clinical Nurse Specialist (CCNS). Each of these roles has specific educational and clinical requirements that must be met obtain certification.

There are several ways in which APRNs contribute to filling the gap. First, APRNs, specifically CNPs in the primary care setting, can diagnose, treat, and manage common acute and chronic illnesses, as well as provide preventive care services. Their advanced training and scope of practice enable them to provide direct primary care for patients. This helps expand access to primary healthcare services, especially in underserved areas where physician shortages are most pronounced. In addition, CNPs work collaboratively with primary care physicians, forming healthcare teams to deliver comprehensive care. By sharing responsibilities, CNPs can help alleviate the workload of physicians and ensure that patients receive timely and coordinated care. This team-based approach enhances efficiency and allows for more patients to be seen and treated effectively.

Further, CNPs are well-positioned to create long-term relationships with their patients and assist in managing chronic conditions, monitor patients’ health, and provide patient education, empowering individuals to make informed decisions about their well-being. This ongoing relationship fosters trust and promotes patient satisfaction. CNPs are trained to educate patients about disease prevention, health promotion, and self-management strategies. By empowering patients with knowledge and tools to maintain their health and prevent illness, CNPs can reduce the burden on primary care physicians by proactively addressing health concerns and preventing the progression of certain conditions. As important, studies have shown that care provided by CNPs is cost-effective.⁶ By delivering primary care services at a lower cost compared to physicians, CNPs can help manage healthcare expenses. This affordability aspect is particularly beneficial for patients without insurance or those with limited financial resources.

In summary, CNPs help address the primary care physician shortage by expanding access to care, working collaboratively with physicians, providing continuity of care, promoting patient education and health, reducing healthcare disparities, delivering cost-effective care, and advocating for primary care. Their contributions are instrumental in improving the availability and quality of primary healthcare services.

Fortunately, the number of CNPs has rapidly grown over the last several years, and the trend is expected to continue in the future. The number of CNPs in the US more than doubled (an increase of 109 percent) in the period 2010–17.⁷ That forecast indicated that in each year between 2016 and 2030, the number of CNPs practicing in the US is expected to grow 6.8 percent—much faster than the projected increase in the number of physicians (1.1 percent). There are projected to be two CNPs for every five physicians in 2030.⁸ Overall growth in the numbers of CNPs has been particularly rapid in outpatient clinics. In Missouri, according to US Bureau of Labor Statistics, there were 2,970 NPs in 2012. In the past 10 years, that number has more than doubled to 7,290 in 2022.⁹

Collaborate: Physician Collaboration and Supervision with APRNs

In Missouri, an APRN is required to have a written collaborative agreement with a supervising physician in order to practice with jointly agreed-upon protocols or standing orders for the delivery of health care services. The supervising physician is responsible for providing oversight and support to the APRN, and for ensuring that the APRN practices within the scope of their education and training. The specific responsibilities of the supervising physician may vary depending on the specific practice setting and the terms of the collaborative agreement.

The scope of practice for APRNs in Missouri is governed by state law and regulations, as well as by the specific education, training, and certification of the individual APRN. In general, APRNs in Missouri are authorized to diagnose and treat medical conditions, prescribe medications, and manage chronic diseases. However, there may be certain procedures or practices that are outside of their scope of practice.

Missouri Revised Statutes § 334.104 and Missouri regulations 20 CSR 2200-4.200 and 20 CSR 2150-5.100 govern collaborative practice agreements between physicians and APRNs. The following is a summary of these requirements:¹⁰

Maximum Number of APRNs per Physician

A collaborating physician cannot enter a collaborative practice arrangement with more than six (6) full-time equivalent APRNs, full-time equivalent licensed physician assistants (or full-time equivalent assistant physicians), or any combination thereof.¹¹

Prescribing Controlled Substances

An APRN cannot prescribe controlled substances unless specifically delegated by the collaborating physician to administer, dispense, or prescribe certain controlled substances.¹² The collaborative practice agreement shall clearly identify the controlled substances that the APRN can prescribe and document that it is consistent with the APRN’s education, knowledge, skill, and competence. An APRN cannot prescribe controlled substances to themselves, or any family as broadly defined by the regulations.¹³

Required Chart Review

An APRN shall maintain adequate and completed patient records. Every 14 days, the collaborating physician must review a minimum of 10% of the total health care services provided by the APRN and a minimum of 20% of the cases in which the APRN prescribed a controlled substance. The collaborating physician must be able to produce documentation of the chart review performed. The agreement must provide a description of the time and manner of the collaborating physician’s review.¹⁴

Geographic Proximity of Physician and APRN

For one (1) month, the APRN must practice at the same location with the collaborating physician continuously present.¹⁵ Thereafter, the arrangements shall not be so geographically distances as to create an impediment to effective collaboration. The collaborating physician and collaborating APRN shall practice within seventy-five (75) miles by road. But, if the APRN is providing services through telehealth, no mileage limit applies.¹⁶

Physician Availability

The collaborating physician or other physician designated in the collaborative practice agreement shall be “immediately available” for consultation at all times – in person or over the phone.¹⁷

Annual Review of Agreement

Each collaborative practice arrangement shall be reviewed at least annually and revised, and documentation of the annual review shall be maintained.¹⁸

Patient Disclosure

Every office where an APRN is authorized to practice in collaboration with a physician must have a prominently displayed disclosure statement informing patients that they may be seen by an APRN and have the right to see the collaborating physician.¹⁹

Manner of the Collaboration

The specific manner of the collaboration must be documented including how they will engage in collaborative practice consistent with each professional’s skill, training, education, and competence and how they will coverage during absence, incapacity, infirmity, or emergency by the collaborating physician.²⁰

Other Specific Terms Required

• Complete names, home, and business addresses, zip codes, and telephone numbers of the collaborating physician and the APRN;²¹

• List of all other offices or locations where the collaborating physician authorized the APRN to prescribe;²²

• List of the collaborating physicians’ specialty or board certifications and all of the APRN’s certifications;²³

• List of all other written practice agreements between the collaborating physician and the APRN;²⁴ and

• The duration of the collaborative practice agreement.²⁵

Listen: Cautionary Case Law and Best Practices

A physician can be held liable for the acts or omissions of an APRN based a number of theories—negligence or medical malpractice, vicarious liability, negligent supervision, or negligent hiring and credentialing. Specifically, a physician may be held responsible for the actions of an APRN if it is alleged that the physician was negligent in their supervisory role or failed to provide appropriate oversight and support to the APRN.

Because of the increasing number of NPs, litigation surrounding collaborative practice agreements will likely increase as well. Even if a physician does not personally treat a patient, they can be liable for injuries the patient suffers simply because of the duties a physician undertakes in a collaborative practice agreement. Consequently, it is extremely important for the physician and APRN to be aware of and strictly adhere to the collaborative practice agreement’s requirements.

Cases around the country tell a cautionary tale to physicians entering into collaborative practice agreements and the liability they could face if they do not adhere to their responsibilities thereunder. In Collip v. Ratts ex rel. Ratts, 49 N.E.3d 607 (Ind. Ct. App. 2015), for example, a physician had a collaborative practice agreement with a NP under which he agreed to review at least 5% of her charts on a weekly basis to evaluate her prescriptive practices. One of the NP’s patients died because of mixed drug intoxication, and the patient’s mother brought a medical malpractice suit against the collaborating physician, arguing that the collaborating physician had a duty to the patient.

The court held that the collaborating physician had a duty to the patient even though he had never treated her or received or reviewed any of her medical records. The court noted that the collaborating physician “voluntarily undertook to enter into the [collaborative practice agreement] and perform the duties required by that agreement. Specifically, he undertook a duty to direct and supervise [the NP] in her practice, including her prescribing practice.” Id. at 616. The collaborating physician admitted that he did not review at least 5% of the NP’s charts as required by the agreement, and “[c]onsequently, there [was] no question that [the collaborating physician’s] failure to exercise reasonable care in performing his duties under the [collaborative practice agreement] increased the risk of physical harm to [the NP’s] patients.” Id. at 610; 616.

1 Picture = 1,000 Words

Source: www.Cision.org

Another court found similarly in Davis v. Texas Medical Board, No. 03–17–00562–CV 2018 WL 1802509 (Tex. Ct. App. Apr. 17, 2018). There, two APRNs, overseen by a collaborating physician, operated clinics wherein they prescribed controlled substances. The Texas Medical Board found that the clinics were “pill mills” at which patients were prescribed non-therapeutic pain medication, including a dangerous combination of drugs. The Texas Medical Board revoked the physician’s license, finding that he was liable for the APRNs’ prescribing practices.

The physician appealed the Texas Medical Board’s decision, contending that he had no knowledge of their inappropriate activities while they were ongoing, he did not encourage these activities, he had no incentive to participate in a “pill mill,” and he terminated his relationships with the APRNs as soon as he discovered their inappropriate activities. Still, the court affirmed the Texas Medical Board’s decision to revoke the physician’s license, holding that he failed to adequately supervise the APRNs’ prescribing practices and document that supervision as required by the collaborative practice agreement. In other words, the physician had a duty to supervise and could rely on inaction as a defense.

There are several best practices that a physician can follow when supervising an APRN:

Carefully Adhere to Requirements of Collaborative Agreements

Review and track obligations for each collaborative agreement and annually evaluate and update agreements as necessary.

Establish Clear Lines of Communication

It is important for the physician and APRN to have open and regular communication to ensure that the patient’s care is coordinated and consistent.

Define Roles and Responsibilities

The physician and APRN should have a clear understanding of their respective roles and responsibilities in the care of the patient.

Develop Written Protocols

The physician and APRN should create guidelines and protocols regarding examinations, assessments, diagnoses, treatment, prescriptive privileges, and administrative functions and specifically describe how often the physician must see the patient, under what circumstances the physician must personally assess a patient, and how to address patient preference to see a physician for certain types of care.

Establish Protocols for Emergency Situations

The physician and APRN should have protocols in place for handling emergency situations, including how to communicate and collaborate in the event of an unexpected outcome or adverse event.

Provide Ongoing Support and Supervision

The physician should provide ongoing support and supervision to the APRN including reviewing treatment plans and prescription history, providing guidance and feedback as needed.

Participate in Ongoing Education and Training

The physician should support the APRN’s ongoing education and professional development and encourage them to stay up-to-date on best practices in their field.

Follow All Relevant Laws and Regulations

The physician should ensure that they and the APRN are following all relevant laws and regulations, including those related to the scope of practice and details set forth in the collaborative agreement.

The number of APRNs has risen substantially in the last several years, and this number is only expected to continue growing. This rise could significantly help temper the effect of the projected physician shortage, but physicians must carefully adhere to statutory and regulatory requirements to prevent liability. Missouri’s collaborative practice requirements are strict, so it is important for physicians to take proactive steps to ensure compliance.