FTC Staff Comment To Representative Jeanne Kirkton, Missouri House of Representatives, Regarding the Competitive Impact of Missouri House Bill 633 On Collaborative Practice Arrangements Between Physicians and Advance Practice Registered Nurses

UNITED STATES OF AMERICA
Federal Trade Commission
WASHINGTON, D.C. 20580
Office of Policy Planning
Bureau of Economics
Bureau of Competition
April 21, 2015
The Honorable Jeanne Kirkton
Missouri House of Representatives
State Capitol – Room 135BC
Jefferson City, MO 65101-6806
Dear Representative Kirkton:
The staffs of the Federal Trade Commission’s (“FTC”) Office of Policy Planning, Bureau of
Economics, and Bureau of Competition1 appreciate the opportunity to respond to your invitation for
comments on Missouri House Bill 633 (“HB633”).2 You have asked us to provide input on the
“competitive impact” of HB633, which would amend Missouri’s Nurse Practice Act to remove some,
and impose other, constraints on collaborative practice arrangements between physicians and
Advance Practice Registered Nurses (“APRNs”). As currently drafted, HB633 may lower the costs of
these arrangements by facilitating electronic collaboration. However, the bill retains a mandatory
collaborative practice structure that FTC staff have identified as raising possible competitive issues.
Additionally, the potential benefits of electronic collaboration may go unrealized unless the new
statutory provisions explicitly supersede, rather than supplement, more onerous regulations that
currently require in-person collaboration.
As discussed in FTC staff’s May 2014 letter3 responding to your invitation for comments on
Missouri House Bills 1481 and 1491 (“HB1481” and “HB1491,” respectively),4 and as explained in
FTC staff’s March 2014 policy paper, Policy Perspectives: Competition and the Regulation of
Advanced Practice Registered Nurses,5 state mandated collaborative practice agreements between
physicians and APRNs raise considerable competitive concerns and may frustrate the development of
innovative and effective models of team-based health care.6 In our 2014 comments, FTC staff noted
that because HB1481 “operated within the confines of mandatory collaborative practice agreements,”
that bill was “likely to be less beneficial for competition and consumers than HB1491.”7 However,
because HB1481 would have permitted electronic collaboration between an APRN and a physician,
we recognized that the bill could potentially lower the costs of mandatory collaborative practice
arrangements. HB633 may, in theory, yield the same benefits of electronic collaboration. These
benefits, however, may not be realized because of new costs potentially imposed by the bill.
Expert bodies, such as the Institute of Medicine, have determined that APRNs are “safe and
effective as independent providers of many health care services within the scope of their training,
licensure, certification and current practice.”8 As such, APRNs can serve a vital role in mitigating the
effects of shortages of primary care providers and reducing problems with access to care that are
most prevalent in less densely populated and lower income areas.9 Within that context, the FTC staff
policy paper examined in detail the evidence and arguments concerning the ability of APRNs to
practice independently. The report also provided an in-depth competitive analysis of statutory and
regulatory provisions governing the scope of practice of APRNs, particularly mandatory

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collaborative practice arrangements. In its policy paper, FTC staff concluded that restrictive
provisions that impede APRNs’ ability to practice independently will likely lead to “decreased access
to health care services, higher health care costs, reduced quality of care, and less innovation in health
care delivery.”10
FTC staff recognize that health and safety are of paramount importance when states regulate
the scope of practice of health care professionals. FTC staff encourage the Missouri legislature to
scrutinize claimed health and safety justifications for its current supervision and collaboration
requirements, review carefully whether any claims of potential patient harm are adequately
substantiated and well founded, and evaluate whether the collaboration requirements are warranted –
not only for APRNs, but also for other health care professionals whose scope of practice would be
affected by HB633.11 If APRNs and other health care professionals are permitted to practice to the
extent of their education, training, and abilities, the state could benefit from enhanced competition,
including potentially lower costs and greater patient access to care. If the current restrictions are
already greater than patient protection requires, we urge the legislature to adopt a bill that removes,
rather than increases, oversight requirements that could further limit the provision of health care
services by APRNs and, perhaps, other members of health care delivery teams.
Overview and Analysis of HB 633
FTC staff encourage innovative forms of collaboration that may foster competition by
APRNs, including innovations based on more effective electronic communication.12 Although
HB633 retains a mandatory collaborative practice arrangement, the bill contains some amendments
that potentially could make these arrangements less burdensome for APRNs and collaborating
physicians, including new statutory provisions that may promote certain forms of electronic
communication and remote chart review. These efficiencies, however, may not outweigh the burdens
imposed by the new responsibilities.
(1) Length of Supervision Period
First, the bill (as approved by the Committee of Professional Registration and Licensing13)
would alter the current requirement that the collaborating physician document at least one month of
supervised practice before the APRN can practice independently. The revised supervision period
would last up to one month, as agreed upon by the APRN and the physician.14 In addition, this
provision would specify that a new supervision period is not required when “the collaborating
physician is new to a patient population to which the collaborating” APRN “is already familiar.”15
These amendments could potentially decrease the amount of time a collaborating physician
must be physically present to supervise the APRN before the APRN can practice independently. As a
result, the bill likely would reduce the costs of collaboration and perhaps help mitigate some
challenges that APRNs face in securing collaborative arrangements. This statutory revision also
likely would minimize disruptions to health care clinics when there is a change in the collaborating
physician. Thus, from a competition perspective, it appears to offer greater potential benefits than the
current law.
(2) Ability for Physician to Review Charts Off-Site
Second, HB633 would effectuate an amendment to provide greater flexibility as to a
collaborating physician’s location when reviewing at least ten percent of the charts documenting the

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APRN’s delivery of health care services.16 The bill would amend the existing statute to specify that
the collaborating physician may perform the chart review off-site. This could facilitate a more
efficient exchange of information among providers and potentially lower the costs of collaboration. If
the collaborating physician has the flexibility to perform chart review remotely, a physician may be
more willing to enter into a collaborative practice arrangement.
(3) Mandatory Consultations for Certain Services
Although the above amendments may facilitate more efficient collaborations, the bill also
contains a new provision that could create additional record-keeping responsibilities for APRNs, as
well as additional consultation and chart review responsibilities for collaborating physicians.
Specifically, HB633 would require the collaborating physician to be available for a consultation in
person or electronically if an APRN provides services for conditions “other than acute, self limiting,
or well defined problems.”17 For “a new or significantly changed condition other than acute self
limiting or well defined problems,” the proposed amendment also would require the collaborating
physician, another physician designated in the collaborative agreement, or the patient’s primary care
physician to review the “patient’s chart and approve or make appropriate modifications to the plan of
treatment.”18 These additional requirements could make it more burdensome for a physician to
collaborate with an APRN or other health care professional specified in the bill, which could result in
fewer physicians who would be willing to collaborate. Moreover, the language describing the
conditions that would trigger these additional oversight responsibilities is vague and may create
uncertainty, which could further discourage physicians from entering into collaboration agreements.
(4) Unclear Whether New Provisions Would Replace or Supplement Existing Ones
As currently worded, it appears that HB633 would not specifically supplant current
regulations that require a physician to meet certain supervisory obligations in person. Thus, in
addition to imposing new burdens, the bill may not achieve the potential efficiencies associated with
off-site chart reviews and consultations. Indeed, these additional responsibilities likely would
increase the costs of collaboration, unless the bill specifically supersedes existing regulatory
requirements.
For example, Missouri regulations currently require the collaborating physician to visit the
APRN clinic at least every two weeks to review records, provide consultations, and be available to
see patients.19 If, as the bill would require, the collaborating physician is available for electronic
consultation and can perform chart reviews remotely, it may not be necessary for the physician to
physically visit the clinic every two weeks. Legislatively removing the more rigid supervision
requirements could promote innovation in health care delivery and quality by allowing providers to
develop and implement practice protocols in accordance with patient and institutional needs.20
Similarly, the regulations currently require the collaborating physician to provide a follow-up
evaluation and visit within two weeks after the patient’s encounter with an APRN for certain new or
significantly changed conditions.21 For the same conditions, HB633 would require the collaborating
physician or the patient’s primary care physician to review the patient’s chart and approve or make
appropriate modifications to the plan of treatment. If the APRN provides the patient’s primary care
physician with a record of the encounter, the primary care physician could effectively follow up with
the patient. If the collaborating physician, in accordance with the current regulations, also must see a
patient within two weeks of the APRN encounter, this likely would create undue inconvenience and

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additional costs for the patient and the collaborating physician without any apparent countervailing
benefits.
As the above examples suggest, HB633 may create new responsibilities in addition to those
in the existing regulations. We respectfully urge the legislature to consider whether these new
responsibilities should explicitly replace existing supervision regulations, which could enable more
flexible collaboration and foster more innovative approaches to care delivery.
Conclusion
FTC staff recognize that, while it is important to promote competition in health care markets,
legislators also must scrutinize relevant safety and quality evidence to determine whether legitimate
safety concerns exist and, if so, whether mandatory collaborative practice requirements are the best
way to address these concerns. Having reviewed the findings of the Institute of Medicine and other
expert bodies on issues of APRN safety, effectiveness, and efficiency, FTC staff have concluded that
the kinds of supervision requirements found in many mandatory collaborative practice agreements do
not appear to be justified by legitimate health and safety concerns. We hope you will carefully
consider this body of research when considering whether there is adequate countervailing evidence to
justify maintaining Missouri’s current collaborative practice requirements.
Although HB633 does not eliminate collaborative practice agreements, it does appear to
allow certain collaborative arrangements that may reduce costs for health care providers and promote
procompetitive innovation in health care delivery. Most of these benefits, however, are more likely to
be realized if certain existing regulatory obligations are removed. FTC staff respectfully recommend
that the Missouri legislature review the current statutory and regulatory requirements to determine
whether HB633 will – or should – supplant more restrictive regulations, and whether the bill is
appropriately tailored to address any legitimate and substantiated health and safety concerns.
We appreciate the opportunity to provide our input on HB633. We hope that our comments
and the FTC staff policy paper will be of assistance as you consider these issues.
Respectfully submitted,
Marina Lao, Director
Office of Policy Planning
Francine Lafontaine, Director
Bureau of Economics
Deborah L. Feinstein, Director
Bureau of Competition

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1 This letter expresses the views of the Federal Trade Commission’s Office of Policy Planning, Bureau of
Economics, and Bureau of Competition. The letter does not necessarily represent the views of the Federal Trade
Commission (“FTC” or “Commission”) or of any individual Commissioner. The Commission, however, has voted
to authorize staff to submit these comments.
2 Letter from the Hon. Jeanne Kirkton, Missouri House of Representatives, to Marina Lao, FTC Office of Policy
Planning (Feb. 25, 2015).
3 Letter from Andrew I. Gavil et al., Federal Trade Commission, to the Hon. Jeanne Kirkton, Missouri House of
Representatives (May 5, 2014) [hereinafter May 2014 FTC Letter].
4 Letter from the Hon. Jeanne Kirkton, Missouri House of Representatives, to Susan S. DeSanti, FTC Office of
Policy Planning (Feb. 18, 2014).
5 FED. T RADE COMM ’N STAFF, P OLICY P ERSPECTIVES: COMPETITION AND THE REGULATION OF ADVANCED P RACTICE
N URSES (2014), https://www.ftc.gov/system/files/documents/reports/policy-perspectives-competition-regulation-
advanced-practice-nurses/140307aprnpolicypaper.pdf [hereinafter FTC STAFF P OLICY P ERSPECTIVES].
6 May 2014 FTC Letter, supra note 3.
7 Id. at 5.
8 FTC STAFF P OLICY P ERSPECTIVES, supra note 5, at 2, n.6 and accompanying text, citing I NST. OF M ED., N AT’ L
ACAD. OF SCIENCES, T HE FUTURE OF N URSING: LEADING C HANGE , ADVANCING H EALTH 98-99 (2011).
9 FTC STAFF P OLICY P ERSPECTIVES, supra note 5, at 25.
10 Id. at 38.
11 HB633, as approved by the Committee of Professional Registration and Licensing on March 12, 2015, would
amend the statute to also include physician assistants and assistant physicians. Although these comments and our
March 2014 policy paper refer specifically to APRNs, we also encourage the legislature to consider our comments,
and scrutinize available health and safety evidence, as it evaluates whether and how to impose mandatory
collaborative practice arrangements on physician assistants and assistant physicians.
12 FTC STAFF P OLICY P ERSPECTIVES, supra note 5, at 4.
13 Unless otherwise indicated, our comments in this letter pertain to the version of HB633 as amended by the
Committee of Professional Registration and Licensing on March 12, 2015.
14 HB633, amending M O. REV. STAT. § 334.104.4(9).
15 Id.
16 HB633, amending M O. REV. STAT. § 334. 104.3(9).
17 HB633, amending M O. REV. STAT. § 334.104.3 to add § 334.104.3(11). Punctuation errors in the original.
18 Id. Punctuation errors in the original.
19 20 CSR 2150-5.100(4) (F), 20 CSR 2200-4.200(4) (F).
20 FTC STAFF P OLICY P ERSPECTIVES, supra note 5, at 31-32.
21 20 CSR 2150-5.100(3) (H), 20 CSR 2200-4.200(3) (H).