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SECOND REGULAR SESSION
HOUSE JOINT
RESOLUTION NO. 187
103RD GENERAL ASSEMBL Y
INTRODUCED BY REPRESENT A TIVE 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 r esolved by the House of Repr esentatives, the Senate concurring ther ein:
That at the next general election to be held in the state of Missouri, on T uesday 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 pr ovider", an assistant physician, physician assistant, or
3 advanced practice re gistered nurse;
4 (2) "Advanced practice regi stered 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 register ed
7 nurse anesthetist;
8 (3) "Board", the state board of nursing;
9 (4) "Collaborative practice arrangement", a written agr eement, jointly agr eed-
10 upon pro tocol, or standing order for the delivery of health care services enter ed into
EXPLANA TION — 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.
11 between a physician and an advanced practice provi der that specifies the manner of
12 collaboration between the collaborating physician and the advanced practice provi der
13 and may delegate to the advanced practice prov ider the authority to administer or
14 dispense drugs and pr ovide tr eatment;
15 (5) "Eligible advanced practice regist ered nurse", an advanced practice
16 r egister ed nurse who is not a certified regi stered nurse anesthetist;
17 (6) "Exempt advanced practice register ed nurse", an advanced practice
18 r egister ed nurse who is exempt fr om the r equir ement 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 r equir ed education, training, certification,
22 demonstrated competencies, and experiences of an advanced practice r egister ed nurse
23 including, but not limited to, the pr escription of pharmacologic and nonpharmacologic
24 therapies.
25 2. An eligible advanced practice regi stered nurse shall not be req uire d to enter
26 into or rem ain in a collaborative practice arrangement in order to practice in this state
27 if the eligible advanced practice r egister ed 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 licensur e 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 requ iring a collaborative practice arrangement or delegation shall
35 not apply to an exempt advanced practice r egister ed nurse.
36 4. (1) Subject to the r equir ements of subdivision (2) of this subsection, an
37 exempt advanced practice r egister ed nurse's pres criptive authority shall include
38 authority to pre scribe, dispense, and administer any medication for which the
39 authority to pr escribe, dispense, or administer may be delegated in a collaborative
40 practice arrangement including, but not limited to, scheduled control led substances
41 specified by general law .
42 (2) An exempt advanced practice regi stered nurse shall not have authority to
43 pr escribe, dispense, or administer a medication unless the exempt advanced practice
44 r egister ed nurse has satisfied all requ irem ents for such prescriptive authority unr elated
45 to practice in a collaborative practice arrangement that ar e pr ovided by general law .
46 The board shall not deny an exempt advanced practice reg istered nurse a certificate of
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47 contr olled substance pr escriptive authority or any other pr escriptive 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 r egistere d nurses shall not:
51 (1) Contain any geographic pr oximity r estrictions, including any mileage or
52 distance res trictions for advanced practice r egistered nurses or physicians. Any such
53 collaborative practice arrangements that contain pr ovisions relat ing to geographic
54 pr oximity requi rem ents shall be deemed unenfor ceable; or
55 (2) Require a collaborating physician to determine and document the completion
56 of a period of time during which the advanced practice regist ered nurse practices with
57 the collaborating physician continuously present before practicing in a setting wher e the
58 collaborating physician is not continuously present .
59 6. A collaborating physician shall not enter into a collaborative practice
60 arrangement with mor e than ten full-time equivalent advanced practice pr oviders. A
61 collaborating physician may exceed the cap of ten advanced practice pr oviders under
62 cir cumstances pr ovided by general law . A collaborating physician shall not be r equir ed
63 to limit the number of advanced practice pr oviders 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) "Accr editation pathway", the accr editation of a res idency progra m as a
3 nationally accr edited res idency pr ogram or a state-accr edited r esidency prog ram;
4 (2) "Board", the state board of regist ration for the healing arts;
5 (3) "Demonstrated workfor ce shortage", a shortage of physicians in a particular
6 specialty as demonstrated by the satisfaction of one or mor e of the following objective
7 criteria:
8 (a) The specialty is identified as experiencing a curr ent or projected shortage in
9 a peer -r eviewed or publicly issued workforce repo rt 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 pro gram; 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. A verage new-patient wait times exceeding thirty days for routine care; or
17 b. Documented physician-to-population ratios below national or state
1 8 benchmarks published by a governmental or academic entity; or
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19 (c) The specialty is the subject of a formal finding or res olution of the general
20 assembly identifying a shortage impacting access to car e;
21 (4) "Health car e prov ider", a hospital, health system, federally qualified health
22 center , or health clinic;
23 (5) "Nationally accred ited res idency pr ogram", a res idency pr ogram accr edited
24 by the Accr editation Council for Graduate Medical Education or its successor
25 organization;
26 (6) "Residency prog ram" or "pr ogram", a postgraduate physician training
27 pr ogram;
28 (7) "Resident physician", a physician enr olled in a res idency pr ogram;
29 (8) "State-accr edited re sidency progr am", a res idency pr ogram appr oved by the
30 board under sections 60 to 81 of this Article.
Section 63. 1. The board shall establish and administer a pr ocess for appr oval of
2 r esidency pro grams as state-accr edited res idency pr ograms.
3 2. Any health car e pr ovider may apply to sponsor a state-accr edited res idency
4 pr ogram.
5 3. Appr oval to operate a state-accr edited res idency pr ogram shall be based
6 solely on compliance with the standards of sections 60 to 81 of this Article.
7 4. The board shall not req uire national or private accre ditation of a res idency
8 pr ogram as a condition of state appr oval.
9 5. The board may promul gate rules to implement application proced ures for
10 r esidency pro grams that apply for appr oval.
Section 66. Each state-accr edited res idency prog ram shall meet the following
2 minimum req uirements:
3 (1) The pro gram shall provi de training of a duration sufficient to ensur e that
4 r esident physicians achieve clinical competency in the applicable specialty . The board
5 shall consider the duration req uirement for training under this subdivision satisfied
6 despite a progr am length shorter than the customary national progra m length if:
7 (a) The pr ogram is in family medicine or another specialty experiencing a
8 demonstrated workforce shortage;
9 (b) The pr ogram demonstrates, thr ough objective competency-based standards,
10 that res ident physicians in the progra m will achieve outcomes for clinical proficien cy ,
11 patient safety , and scope-of-practice rea diness equivalent to those achieved by graduates
12 of longer pr ograms;
13 (c) The shortened duration does not eliminate essential clinical rota tions or
14 r equir ed core competencies for the specialty; and
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15 (d) The pro gram includes enhanced supervision, evaluation, and competency
16 verification mechanisms sufficient to ensur e that the quality of training is not
17 diminished;
18 (2) The pr ogram shall ensur e that the practice of medicine by res ident
19 physicians is under the supervision of physicians who hold an unr estricted license to
20 practice medicine in this state and who possess demonstrated competence in the
21 specialty ar ea;
22 (3) The pro gram shall ensur e that the patient volume and diversity of clinical
23 experience ar e sufficient for re sident physicians to achieve competency in the specialty;
24 (4) The prog ram shall implement written evaluation, re mediation, and dismissal
25 pr ocedur es for the res ident physicians; and
26 (5) The pr ogram shall comply with all applicable state laws rel ating to patient
27 safety , quality r eporting, and pr ofessional conduct.
Section 69. 1. Every applicant for a permanent license as a physician shall
2 pr ovide the board with satisfactory evidence of having successfully completed:
3 (1) A nationally accr edited r esidency prog ram; or
4 (2) A state-accre dited res idency pr ogram appr oved by the board under sections
5 60 to 81 of this Article.
6 2. The board shall not r equir e any postgraduate training in addition to the
7 postgraduate training in a r esidency progra m r equir ed under this section to obtain
8 permanent licensur e as a physician.
9 3. The board shall not vary the r equir ements for licensure as a physician based
10 on the accred itation pathway of the res idency pr ogram 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 accred itation pathway of the res idency pr ogram 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 accr editation pathway of the re sidency pr ogram
6 completed by the physician.
Section 75. 1. Any denial, limitation, or revoca tion of appr oval of a state-
2 accr edited r esidency pr ogram shall be based solely on failur e to meet expr ess
3 constitutional r equir ements. Any denial, limitation, or revoca tion shall be in writing
4 and state the specific constitutional gr ounds for the action.
5 2. Any state-accr edited res idency pr ogram that has had its appr oval denied,
6 limited, or revok ed by the board may seek a review of the board's action by the
7 administrative hearing commission or its successor entity .
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8 3. This section shall not be construed to grant the board authority to impose
9 r equir ements not expr essly 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-accr edited res idency
4 pr ogram for the purposes of licensur e or authorization to practice in that state.
5 2. Nothing in sections 60 to 81 of this Article shall be construed to limit, repl ace,
6 or interfer e with nationally accr edited r esidency prog rams operating within this state.
7 3. The department of social services may seek any federal waiver , state plan
8 amendment, or other federal appr oval necessary to maximize federal re imbursement of
9 health care services pr ovided by re sident physicians consistent with sections 60 to 81 of
10 this Article.
Section 81. Befor e January 1, 2037, and every ten years ther eafter , the board
2 shall submit a rep ort to the general assembly containing:
3 (1) Data on the state-accr edited resi dency progra ms appr oved by the board
4 including, but not limited to:
5 (a) The number of prog rams appr oved by the board;
6 (b) The geographic r egions in which the pr ograms primarily operate;
7 (c) The number and type of specialties offer ed by the pro grams; and
8 (d) The number of physicians who graduated from the pro grams;
9 (2) Data on the workforce participation of graduates of state-accr edited
10 r esidency pro grams, including data disaggr egated by specialty , type of employer , and
11 geographic region ;
12 (3) Data on the outcomes for clinical pro ficiency , patient safety , and scope-of-
13 practice read iness achieved by graduates of state-accr edited res idency pro grams as
14 compar ed to the outcomes achieved by graduates of nationally accre dited res idency
15 pr ograms; and
16 (4) Data on insurance r eimbursement practices for health car e services pr ovided
17 by r esident physicians and graduates of state-accre dited r esidency prog rams.
✔
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