Restrictions on the number of supervision agreements and collaboration agreements an Illinois physician may maintain require careful oversight and knowledge of the need to ensure compliance with these limitations.  Changes to the statutes governing physician assistant practice passed in August 2012 have broad-reaching effects that hospitals, health care facilities and medical groups are just now coming to understand—and show that sometimes compliance is not as easy as being told to “count to five.”


Changes to the Physician Assistant Practice Act of 1987 (PA Practice Act), 225 Ill. Comp. Stat. 95/et seq., passed into law in August 2012, fundamentally alter the type and number of supervision and collaboration relationships that an Illinois physician may engage in.  The changes, which were met with little attention by health care publications, are proving problematic as health care facilities and practices that regularly work with mid-level providers evaluate contractual terms in the new year.

Effective as of August 24, 2012, the PA Practice Act was revised to change the previously established limit of two physician assistant (PA) supervision agreements per physician to a new, seemingly broader limit of five.  225 Ill. Comp. Stat. 95/7(a).  However, the revision qualified the new PA limit by requiring an offset for the number of collaboration agreements that a physician simultaneously has in place with advanced practice nurses (APNs).  While the number of APN collaboration agreements a physician may enter into is unlimited (so long as the number is not found to be “excessive” by the Illinois Department of Financial and Professional Regulation), the restriction in the PA Practice Act functions to limit the number of APN collaboration agreements a physician may enter into when that same physician also has entered into supervision agreements with PAs.

Interestingly, neither the Medical Practice Act of 1987, 225 Ill. Comp. Stat. 60/et seq., nor the Nurse Practice Act, 225 Ill. Comp. Stat. 65/et seq., were revised to reflect these changes.  Notwithstanding the clarification that such analogous changes would have provided, the restrictions in the PA Practice Act apply to any situation involving PA supervision.

Examples of the new need to “count to five” for arrangements with physicians and mid-levels include:

  • Dr. A has entered into supervision agreements with two PAs and collaboration agreements with three APNs.  He is prohibited from entering into any additional supervision or collaboration agreements to avoid exceeding a combined total of five agreements. 
  • Dr. B has collaboration agreements with five APNs, and wants to enter into a supervision agreement with a PA.  She can only do so if she terminates one of the collaboration agreements with an APN to keep the combined total at five. 
  • Dr. C has entered into two supervision agreements with PAs and four collaboration agreements with APNs.  He must promptly terminate one of the APN or PA agreements in order to have the collective total not exceed five.
  • Dr. D has entered into five collaboration agreements with APNs and desires to add another.  This is permissible so long as she does not also enter into supervision agreement with a PA (as the number of collaboration agreements with APNs alone is not restricted). 

Regulations related to the revised provisions of the PA Practice Act have not yet been promulgated, but it is not anticipated that the regulations will qualify the five agreement limit or establish exemptions to the requirement, as none are indentified in the statute. 

Hospitals, health care facilities and groups that employ mid-level providers and provide oversight of their supervision and collaboration agreements should be aware of these restrictions, and evaluate current relationships to ensure new and existing arrangements are compliant.  Hospitals and licensed health care facilities that grant clinical privileges to mid-levels (which process can obviate the requirement for a written agreement for PAs (225 Ill. Comp. Stat. 95/7.7) and APNs (225 Ill. Comp. Stat. 65/65–45)) will not be as affected by this change.