HOUSE JOINT RESOLUTION NO. 187 103RD GENERAL ASSEMBLY
INTRODUCED BY REPRESENTATIVE OVERCAST.
7094H.01I JOSEPH ENGLER, Chief Clerk
JOINT RESOLUTION Submitting to the qualified voters of Missouri an amendment to Article IV of the Constitution of Missouri, by adopting nine new sections relating to health care professionals.
Be it resolved by the House of Representatives, the Senate concurring therein:
That at the next general election to be held in the state of Missouri, on Tuesday next 2 following the first Monday in November, 2026, or at a special election to be called by the 3 governor for that purpose, there is hereby submitted to the qualified voters of this state, for 4 adoption or rejection, the following amendment to Article IV of the Constitution of the state 5 of Missouri: Section A. Article IV, Constitution of Missouri, is amended by adopting nine new 2 sections, to be known as Sections 55, 60, 63, 66, 69, 72, 75, 78, and 81, to read as follows: Section 55. 1. As used in this section, the following terms mean: 2 (1) "Advanced practice provider", an assistant physician, physician assistant, or 3 advanced practice registered nurse; 4 (2) "Advanced practice registered nurse", a person who is licensed by the board 5 to engage in the practice of advanced practice nursing as a certified clinical nurse 6 specialist, certified nurse midwife, certified nurse practitioner, or certified registered 7 nurse anesthetist; 8 (3) "Board", the state board of nursing; 9 (4) "Collaborative practice arrangement", a written agreement, jointly agreed- 10 upon protocol, or standing order for the delivery of health care services entered into
EXPLANATION — Matter enclosed in bold-faced brackets [thus] in the above bill is not enacted and is intended to be omitted from the law. Matter in bold-face type in the above bill is proposed language. HJR 187 2
11 between a physician and an advanced practice provider that specifies the manner of 12 collaboration between the collaborating physician and the advanced practice provider 13 and may delegate to the advanced practice provider the authority to administer or 14 dispense drugs and provide treatment; 15 (5) "Eligible advanced practice registered nurse", an advanced practice 16 registered nurse who is not a certified registered nurse anesthetist; 17 (6) "Exempt advanced practice registered nurse", an advanced practice 18 registered nurse who is exempt from the requirement to work in a collaborative practice 19 arrangement under subsection 2 of this section; 20 (7) "Practice of advanced practice nursing", the performance for compensation 21 of activities and services consistent with the required education, training, certification, 22 demonstrated competencies, and experiences of an advanced practice registered nurse 23 including, but not limited to, the prescription of pharmacologic and nonpharmacologic 24 therapies. 25 2. An eligible advanced practice registered nurse shall not be required to enter 26 into or remain in a collaborative practice arrangement in order to practice in this state 27 if the eligible advanced practice registered nurse: 28 (1) Has a license in good standing and has been in a collaborative practice 29 arrangement or arrangements for a cumulative total of two thousand documented hours 30 with a collaborating physician or physicians; or 31 (2) Has applied for and received licensure by endorsement and successfully 32 demonstrated at the time of such application to the board the completion of a 33 cumulative total of two thousand documented hours of practice. 34 3. Any law requiring a collaborative practice arrangement or delegation shall 35 not apply to an exempt advanced practice registered nurse. 36 4. (1) Subject to the requirements of subdivision (2) of this subsection, an 37 exempt advanced practice registered nurse's prescriptive authority shall include 38 authority to prescribe, dispense, and administer any medication for which the 39 authority to prescribe, dispense, or administer may be delegated in a collaborative 40 practice arrangement including, but not limited to, scheduled controlled substances 41 specified by general law. 42 (2) An exempt advanced practice registered nurse shall not have authority to 43 prescribe, dispense, or administer a medication unless the exempt advanced practice 44 registered nurse has satisfied all requirements for such prescriptive authority unrelated 45 to practice in a collaborative practice arrangement that are provided by general law. 46 The board shall not deny an exempt advanced practice registered nurse a certificate of HJR 187 3
47 controlled substance prescriptive authority or any other prescriptive authority on the 48 basis that the nurse does not practice in a collaborative practice arrangement. 49 5. Collaborative practice arrangements between physicians and advanced 50 practice registered nurses shall not: 51 (1) Contain any geographic proximity restrictions, including any mileage or 52 distance restrictions for advanced practice registered nurses or physicians. Any such 53 collaborative practice arrangements that contain provisions relating to geographic 54 proximity requirements shall be deemed unenforceable; or 55 (2) Require a collaborating physician to determine and document the completion 56 of a period of time during which the advanced practice registered nurse practices with 57 the collaborating physician continuously present before practicing in a setting where the 58 collaborating physician is not continuously present. 59 6. A collaborating physician shall not enter into a collaborative practice 60 arrangement with more than ten full-time equivalent advanced practice providers. A 61 collaborating physician may exceed the cap of ten advanced practice providers under 62 circumstances provided by general law. A collaborating physician shall not be required 63 to limit the number of advanced practice providers with whom he or she collaborates to 64 a number less than ten. Section 60. As used in sections 60 to 81 of this Article, the following terms mean: 2 (1) "Accreditation pathway", the accreditation of a residency program as a 3 nationally accredited residency program or a state-accredited residency program; 4 (2) "Board", the state board of registration for the healing arts; 5 (3) "Demonstrated workforce shortage", a shortage of physicians in a particular 6 specialty as demonstrated by the satisfaction of one or more of the following objective 7 criteria: 8 (a) The specialty is identified as experiencing a current or projected shortage in 9 a peer-reviewed or publicly issued workforce report by: 10 a. The department of health and senior services; 11 b. The Missouri Hospital Association; 12 c. A state university medical or public health program; or 13 d. A federal agency with jurisdiction over health workforce analysis; 14 (b) The specialty demonstrates persistent access deficiencies including, but not 15 limited to: 16 a. Average new-patient wait times exceeding thirty days for routine care; or 17 b. Documented physician-to-population ratios below national or state 18 benchmarks published by a governmental or academic entity; or HJR 187 4
19 (c) The specialty is the subject of a formal finding or resolution of the general 20 assembly identifying a shortage impacting access to care; 21 (4) "Health care provider", a hospital, health system, federally qualified health 22 center, or health clinic; 23 (5) "Nationally accredited residency program", a residency program accredited 24 by the Accreditation Council for Graduate Medical Education or its successor 25 organization; 26 (6) "Residency program" or "program", a postgraduate physician training 27 program; 28 (7) "Resident physician", a physician enrolled in a residency program; 29 (8) "State-accredited residency program", a residency program approved by the 30 board under sections 60 to 81 of this Article. Section 63. 1. The board shall establish and administer a process for approval of 2 residency programs as state-accredited residency programs. 3 2. Any health care provider may apply to sponsor a state-accredited residency 4 program. 5 3. Approval to operate a state-accredited residency program shall be based 6 solely on compliance with the standards of sections 60 to 81 of this Article. 7 4. The board shall not require national or private accreditation of a residency 8 program as a condition of state approval. 9 5. The board may promulgate rules to implement application procedures for 10 residency programs that apply for approval. Section 66. Each state-accredited residency program shall meet the following 2 minimum requirements: 3 (1) The program shall provide training of a duration sufficient to ensure that 4 resident physicians achieve clinical competency in the applicable specialty. The board 5 shall consider the duration requirement for training under this subdivision satisfied 6 despite a program length shorter than the customary national program length if: 7 (a) The program is in family medicine or another specialty experiencing a 8 demonstrated workforce shortage; 9 (b) The program demonstrates, through objective competency-based standards, 10 that resident physicians in the program will achieve outcomes for clinical proficiency, 11 patient safety, and scope-of-practice readiness equivalent to those achieved by graduates 12 of longer programs; 13 (c) The shortened duration does not eliminate essential clinical rotations or 14 required core competencies for the specialty; and HJR 187 5
15 (d) The program includes enhanced supervision, evaluation, and competency 16 verification mechanisms sufficient to ensure that the quality of training is not 17 diminished; 18 (2) The program shall ensure that the practice of medicine by resident 19 physicians is under the supervision of physicians who hold an unrestricted license to 20 practice medicine in this state and who possess demonstrated competence in the 21 specialty area; 22 (3) The program shall ensure that the patient volume and diversity of clinical 23 experience are sufficient for resident physicians to achieve competency in the specialty; 24 (4) The program shall implement written evaluation, remediation, and dismissal 25 procedures for the resident physicians; and 26 (5) The program shall comply with all applicable state laws relating to patient 27 safety, quality reporting, and professional conduct. Section 69. 1. Every applicant for a permanent license as a physician shall 2 provide the board with satisfactory evidence of having successfully completed: 3 (1) A nationally accredited residency program; or 4 (2) A state-accredited residency program approved by the board under sections 5 60 to 81 of this Article. 6 2. The board shall not require any postgraduate training in addition to the 7 postgraduate training in a residency program required under this section to obtain 8 permanent licensure as a physician. 9 3. The board shall not vary the requirements for licensure as a physician based 10 on the accreditation pathway of the residency program completed by the physician. Section 72. 1. The privilege of a physician licensed in this state to practice 2 medicine in any hospital, clinic, or health care facility in this state shall not vary based 3 on the accreditation pathway of the residency program completed by the physician. 4 2. A hospital or health system shall not deny staff privileges to a physician 5 licensed in this state based solely on the accreditation pathway of the residency program 6 completed by the physician. Section 75. 1. Any denial, limitation, or revocation of approval of a state- 2 accredited residency program shall be based solely on failure to meet express 3 constitutional requirements. Any denial, limitation, or revocation shall be in writing 4 and state the specific constitutional grounds for the action. 5 2. Any state-accredited residency program that has had its approval denied, 6 limited, or revoked by the board may seek a review of the board's action by the 7 administrative hearing commission or its successor entity. HJR 187 6
8 3. This section shall not be construed to grant the board authority to impose 9 requirements not expressly authorized by sections 60 to 81 of this Article. Section 78. 1. Nothing in sections 60 to 81 of this Article shall be construed to: 2 (1) Guarantee eligibility for federal graduate medical education funding; or 3 (2) Require any other state to accept completion of a state-accredited residency 4 program for the purposes of licensure or authorization to practice in that state. 5 2. Nothing in sections 60 to 81 of this Article shall be construed to limit, replace, 6 or interfere with nationally accredited residency programs operating within this state. 7 3. The department of social services may seek any federal waiver, state plan 8 amendment, or other federal approval necessary to maximize federal reimbursement of 9 health care services provided by resident physicians consistent with sections 60 to 81 of 10 this Article. Section 81. Before January 1, 2037, and every ten years thereafter, the board 2 shall submit a report to the general assembly containing: 3 (1) Data on the state-accredited residency programs approved by the board 4 including, but not limited to: 5 (a) The number of programs approved by the board; 6 (b) The geographic regions in which the programs primarily operate; 7 (c) The number and type of specialties offered by the programs; and 8 (d) The number of physicians who graduated from the programs; 9 (2) Data on the workforce participation of graduates of state-accredited 10 residency programs, including data disaggregated by specialty, type of employer, and 11 geographic region; 12 (3) Data on the outcomes for clinical proficiency, patient safety, and scope-of- 13 practice readiness achieved by graduates of state-accredited residency programs as 14 compared to the outcomes achieved by graduates of nationally accredited residency 15 programs; and 16 (4) Data on insurance reimbursement practices for health care services provided 17 by resident physicians and graduates of state-accredited residency programs. ✔