How Delaware’s Four-Physician-Associate Collaboration Cap Works 

This article is part of a series on Delaware’s new Physician Associate Act. Start with Delaware’s New Physician Associate Act: What Changed and Who It Affects. 

A practice that wants to add clinical capacity by hiring physician associates will, sooner or later, run into a numerical limit on how many of them a single physician may collaborate with. Delaware’s House Bill 325, signed May 12, 2026, gave experienced physician associates a path to independent practice and drew most of the attention this year, but it did not change that limit. 

For practices, then, the operative question is not what the new law permits. It is how the existing cap is counted, what falls outside it, and who bears the consequence when it is exceeded. 

How the cap is counted 

Under 24 Del. C. § 1771, a collaborating physician may not, at any given time, collaborate with more than four active physician associates unless the Board of Medical Licensure and Discipline increases or decreases that number by regulation. 

The Board’s regulation clarifies that this is a concurrent, point-in-time limit rather than a limit on the number of relationships a physician may have. A physician “is only restricted to 4 physician[] assistants during 1 shift or while performing clinical work” and “may enter into collaborative agreements with more than 4,” provided that no more than four collaborate at once. (24 DE Admin. Code 1700-13.0.) 

That distinction is where compliance problems tend to arise, because practices generally count signed agreements while the statute counts simultaneous coverage. A group with six collaborative agreements on file and never more than four physician associates on a given shift is compliant. A group with four agreements and a Saturday on which all four overlap with a fifth physician associate covering under an informal arrangement is not. 

Who bears the risk 

It is worth noting where the exposure sits. A physician who collaborates in violation of the cap is subject to discipline by the Board for permitting the unauthorized practice of medicine. 

That characterization follows a physician through credentialing, payor contracting, and licensure renewal. Thus, while the practice absorbs the operational disruption of a coverage failure, the physician absorbs the professional consequence, which is a reason to treat the cap as a governance matter rather than a scheduling matter. 

What the cap does not reach 

Three categories fall outside the four-physician-associate limit. 

1. Shared physical space. The cap does not apply to physicians and physician associates practicing in the same physical office or facility building, an emergency department being the statute’s own example, so long as there is active physician coverage. This is the broadest exception available to a brick-and-mortar practice, and it is worth confirming that the coverage in question is genuinely active rather than nominal. 

2. Nurse practitioners. Delaware advanced practice registered nurses are independent licensed practitioners under the exclusive licensure authority of the Board of Nursing. There is no collaborating-physician requirement, no ratio, and no cap; consultation is required only “as appropriate,” and an advanced practice registered nurse is held to no lesser standard of care than a physician. (24 Del. C. §§ 1902, 1935.) Where the constraint a practice is actually solving for is clinical capacity rather than physician associate capacity specifically, nurse practitioners may be the more direct path. 

3. Physician associates holding independent practice authority, probably. The cap counts physician associates a physician “collaborate[s] with,” and a physician associate holding independent practice authority has no collaborative agreement by definition. The statutory text therefore indicates that such physician associates fall outside the four. 

That last reading is textually sound based on the language of the statute but has not been confirmed. The Board’s regulation predates the independent practice authority amendments, offers no guidance on a roster combining collaborating and independent physician associates, and no Board interpretation has surfaced. Before adopting a staffing model that depends on the point, a practice would be well advised to seek written confirmation from the Board, because the consequence of being wrong is a disciplinary finding against its physicians. 

Options for expanding physician associate capacity 

Several compliant approaches are available, and most practices have more room than they realize. 

• Stagger schedules so that no physician collaborates with more than four physician associates at once. This is the least expensive option and the one most often overlooked, because the cap is generally read as a headcount problem when it is in fact a calendar problem. 

• Obviously, adding collaborating physicians would allow for an additional four-physician-associate allotment. 

• Use the same-building exception where a physician is on site with active coverage. 

• Prioritize physician associates who will qualify for independent practice authority, subject to the caveat above. 

• Seek a Board exemption. The Board may increase the number upon a written application showing good cause, decided case by case, with the physician bearing the burden of demonstrating no danger to the public health, safety, or welfare. 

• Maintain genuine collaboration. The collaborating physician “may not be involved in patient care in name only and must be involved in active patient care on a regular basis,” with defined scope, access, and performance-evaluation processes. A collaborating physician in name only will not survive scrutiny, and again, the risk attaches to the physician. 

TIP: Because the cap is measured at a point in time, the most useful compliance document is not the roster of collaborative agreements but the schedule. A practice that can produce a shift-by-shift record showing that no physician exceeded four concurrent collaborations is in a substantially better position than one that can produce only its agreements. 

Planning for physician associate departures 

There is a second-order effect of the new law that practices may want to consider now rather than later. 

A physician associate with more than 6,000 post-graduate clinical hours, which is roughly three to four years of full-time practice, will shortly be able to apply to practice independently. Until May of this year, that was not a realistic option in Delaware. Independent practice authority therefore gives a practice’s most experienced physician associates an alternative they did not previously have, and the physician associates most likely to pursue it are generally the ones a practice would least like to lose. 

Three steps are worth taking while the regulations remain pending. 

1. Identify which physician associates are at or approaching the 6,000-hour threshold. Most practices do not track this, because until recently there was no reason to. 

2. Revisit compensation, autonomy, and partnership-track arrangements for that group specifically. A physician associate weighing independence is comparing the practice’s offer against a business plan rather than against another employer’s salary range. 

3. Review notice provisions and post-employment terms in physician associate agreements, ideally before the regulations issue rather than after. 

Conclusion 

The cap is measured at a point in time rather than by agreements on file; the disciplinary exposure runs to the collaborating physician rather than to the practice entity; and several categories of clinician, including nurse practitioners and probably physician associates holding independent practice authority, fall outside the limit altogether. 

Practices that have not recently audited their collaboration coverage against a schedule, rather than against a personnel roster, are advised to do so, and to confirm any assumptions about independent practice authority with the Board before building them into a staffing plan. 

Also in this series: [Independent Practice Authority for Delaware Physician Associates] and [Telehealth, Limited Liability Companies, and Independent Practice] 

Andy Silverman is a partner in the Business Department at MacElree Harvey, Ltd. He advises medical practices and providers on business structure and governance, equity and physician compensation arrangements, employment agreements, private equity and M&A transactions, and regulatory and tax matters. Admitted in both Delaware and Pennsylvania, he holds an LL.M. in Taxation from Villanova University School of Law and is a member of the American Health Law Association. 

This article reflects Delaware law as of August 4, 2026. The Regulatory Council’s implementing regulations had not been adopted as of publication. 

This article is for general informational purposes and does not constitute legal advice or create an attorney-client relationship. Attorney advertising.