FTC asks Missouri lawmakers to reconsider APRN safety and competition

The Federal Trade Commission (FTC) submitted written comments on a proposed Missouri law that would modify the collaborative practice arrangements imposed on Advanced Practice Registered Nurses (APRNs) and limit the authority of APRNs to provide services. The FTC comments urge Missouri lawmakers to make certain that the stricter APRN requirements are warranted in light of alleged patient safety concerns. The agency comments assert that unnecessary legislative burdens on APRNs run the risk of increasing health care costs while decreasing competition and access to care.

Bill 633

Under current Missouri law, APRNs are required to enter into a collaborative practice arrangement with a specific physician in order to assess and diagnose patients. APRNs also need a collaborative practice arrangement to order diagnostic and therapeutic tests and procedures. The proposed law, Missouri House Bill 633, would remove some constraints on the collaborative practice arrangements between physicians and APRNS, while imposing some additional constraints. Specifically, the law would impose additional recordkeeping, consultation, and chart review responsibilities for APRNs. The FTC comments acknowledge that, as currently drafted, HB633 “may lower the costs of these arrangements by facilitating electronic collaboration.”

Practice structure

The primary focus of the FTC comments is the collaborative practice arrangement itself and the agency’s concern that it raises possible competitive issues. Through its comments, the FTC reiterated a position that it established in a March 2014 Policy Perspective (see FTC offers state legislatures some principles for evaluating APRN scope of practice restrictions, Health Law Daily, March 10, 2014). The agency cautioned that, although the state asserted health and safety concerns as the basis for the collaborative practice arrangement, the arrangements may be unnecessarily burdensome because APRNs have been demonstrated to be “safe and effective as independent providers of many health care services within the scope of their training, licensure, certification and current practice.” As a result, the FTC comments asked Missouri legislature to “scrutinize claimed health and safety justifications” for the current requirements so that a determination can be made as to “whether the collaboration requirements are warranted.”


Despite several concerns, the FTC praised a provision of the Missouri proposal that would decrease the length of an APRN’s supervision period prior to the authorization of independent practice. The comments also were supportive of a provision allowing supervising physicians to conduct off-site review of APRN documentation of patient charts. The FTC was cautious about the potential effects of other provisions, including one provision that would impose additional record keeping obligations on APRNs for certain patient conditions and circumstances.