With health care reform taking shape over the next few months – and with it transformational changes in the way care is delivered and how providers are paid – mid-sized independent physician groups and smaller practices are increasingly being confronted with a decision: merge, partner or have the practice acquired in an effort to survive the rapidly shifting landscape.

In the North Bay, Sonoma County is home to two of the largest independent physician groups – 41-member Redwood Regional Medical Group and the  50-member Northern California Medical Associates – while Marin County is home to a large foundation itself in the Prima Medical Group.

Napa County, on the other hand, is dominated mainly by large health systems and their associated physicians groups -- Adventist Health and St. Joseph Health -- along with a smattering of small independent practices.

Both Redwood Regional and NCMA are acutely aware of the sea changes, and each said it has explored or is exploring options related to the trend of consolidation and partnerships, particularly as bundled payments loom as the replacement of the fee-for-service model that many regard as the main nexus for reform.

“In this ever-changing health care environment, Redwood has started to explore a potential long-term model for physicians who wish to maintain a degree of independence and self-governance,” said Wayne Fairchild, chief executive officer of Redwood Regional, which specializes in oncology, radiology and orthopedics.

Likewise, NCMA, which has numerous specialties, has explored its options as the  group plots is post Affordable Care Act strategy, according to Ruth Skidmore, chief executive officer.

One of those options, she said, included a merger with a large regional medical foundation, but the group decided to take a step back and not join with another group too quickly.

“We made that decision because we really wanted to take a step back and evaluate to see what the changes from [Washington] D.C. really mean,” Ms. Skidmore said, similarly citing physician autonomy as a key aspect for the group.

Meanwhile in Marin, the Prima Medical Group has made clear that it will seek partnerships, along with the nearly 600-strong physician network Marin-Sonoma IPA, with hospitals and other providers in forming an accountable care organization, or ACO. Such organizations are encouraged under reform by way of bonuses from the Centers for Medicare and Medicaid Services, which is overseeing several key elements of the ACA.

The move toward ACOs, along with the march toward electronic medical records and inconsistent patient volumes are all confronting the small and mid-sized independent groups, said Mark Knight, a health care consultant formerly of St. Joseph Health.

“Those are factors that, if you are awake and aware and alert, are forcing you to look at how you’re going to do business and provide care in the future,” Mr. Knight said. “You’re seeing all sorts of partnerships and I think you’re going to see more."

While the mid-sized groups look to align in the most sensible manner, the smaller groups and independent physicians will face an even tougher time in the marketplace, Mr. Knight said.

Ms. Skidmore, of NCMA, also noted that electronic health records are still something that all groups and practices are contending with, particularly as integration and better communication is sought between providers.

“We’re working with everyone across the region looking at cost containment and enhanced communications to talk across EMR systems,” she said. “That’s still a big focal point.”

Although NCMA remains independent, Ms. Skidmore said the group would continue to work closely with some of the region’s larger providers, including Santa Rosa Memorial Hospital, owned by St. Joseph Health, and Adventist Health, particularly in northern Napa and Lake counties, where NCMA physicians will practice interventional cardiology.

The group will also consider other possible scenarios – from partnerships to ACOs to merging – depending on the parties involved. What is less likely, Ms. Skidmore said,  is that the group will merge with an insurer or hospital chain.

“We hear these partnerships are increasing, so we’re just going to step back and grow in our regions,” Ms. Skidmore said. “We’ll talk to different parties as they come available.”

The pace of mergers and acquisitions among physicians groups has accelerated, and along with that have been some unusual partnerships, Mr. Knight said, ranging from insurers purchasing hospitals to DaVita, a dialysis company, acquiring Torrance-based HealthCare Partners, which operates medical groups and networks, for $3.7 billion.

A more likely fit for NCMA, Ms. Skidmore said, is perhaps one of the university-based health systems like Stanford or UCSF.

Even as the partnerships increase -- and even as they turn more heads -- Ms. Skidmore said she wasn't concerned the group would get left behind.

"We feel like we're large enough that we could be included with a partner that makes sense," she said. "I think we'd still get an invitation to the party."