In a consolidated market dominated by large health care institutions, some doctors have carved out a space to practice independently, despite the many forces working against physicians setting out on their own.

In 2016, Dr. Rebecca Ware decided to leave the Cleveland Clinic — where she'd practiced primary care at the Lorain Family Health & Surgery Center since 2004 — and venture out to practice independently.

Her biggest hesitations over the move concerned whether patients would follow and how easily she'd be able to refer those patients to other doctors they'd need to see. Most patients happily followed, she said, and the health systems have made it fairly easy for independent physicians to refer patients.

In Northeast Ohio, the health care giants have an important role, said Ware, who's now an internist with Northshore Healthcare, an independent physician group.

"But with primary care, I think it's different," she said. "Patients want that established relationship with their doctor, and in the big systems, we tend to lose that a little bit."

Many docs are choosing to punt the regulatory headaches and administrative burdens of running a practice in favor of working for a larger hospital system that can handle that work for them. For example, 2016 was the first year nationally in which fewer than half of patient-care physicians had an ownership stake in their practice, according to a 2017 report from the American Medical Association. It was also the first year when there was an equal portion, 47.1%, of physicians who were employees and owners.

Northeast Ohio's physician environment is, of course, fairly consolidated among the large health systems like the Clinic and University Hospitals, but many independent doctors believe this is a region where they can still practice and even thrive.

For example, NOMS Healthcare has been experiencing rapid growth in the number of physicians who want to practice independently. In two and a half years, the Sandusky-based physician-owned and led medical practice grew from 60 providers to more than 200, with most of that growth in the Toledo and Cleveland areas.

NOMS chief strategic officer Rick Schneider said he sees many physicians who are ready to go back to independent practice, but who remain nervous without a platform like a physician group to navigate through various governmental and regulation issues.

"I think now that they're seeing that there are platforms out there, independent platforms out there, that's one of the real reasons why we're seeing this surge in growth," he said.

Last year, a team of independent doctors announced they're building a specialty hospital in Beachwood. The for-profit, full-service hospital will specialize in orthopedics, urology, general surgery and gastrointestinal procedures and is looking to attract high-quality, independent doctors.

Dr. Reuben Gobezie, who's part of the team behind that hospital, moved into independence in 2012 and has started various practices. The entrepreneurial former University Hospitals doctor says being independent allows him to practice medicine and treat patients the way he wants to, rather than being confined by guidelines of a large institution, which he calls "too limiting."

"Building this hospital that we're building, that is tangible evidence (that) the pendulum has just swung so far over toward institutionalized medicine," Gobezie said. "The pendulum is starting to swing back."

How far back that pendulum will swing is yet to be seen, considering the hurdles doctors face.

Kathryn Hickner, an attorney who co-chairs the health care practice group at Ulmer & Berne, said it is increasingly difficult for independent physicians to thrive in the way they used to thrive financially.

"Based upon my discussions with clients, they often want to align with larger groups and institutions in order to mitigate the burden of running a practice," Hickner said. "It's a reaction to the increasing expense of running a practice because of the MACRA reporting requirements, for example, or EHRs (or) the cost of employee health benefits."

MACRA — the Medicare Access and CHIP Reauthorization Act of 2015 — creates a payment framework for rewarding physicians for providing higher quality care. MACRA, along with electronic health records, or EHRs, administrative burdens and more make up a long list of reasons physicians align with a bigger health system, Hickner said.

While the recently passed federal tax law isn't likely to be a driving factor in decisions on whether to align with a system, it has a couple of wins for those doctors who wish to remain independent.

For one, the tax rate for C-corporations was reduced from 35% to 21%. The second change impacts physicians conducting their practice through a pass-through entity, which Hickner said in her experience is more common. A 20% pass-through deduction will benefit some physicians who meet certain criteria and make below a certain threshold.

"In my experience working with physicians, the decision to align with a larger system is a very difficult one, and there are many, many factors that go into that decision," Hickner said. "I would be surprised if this was a catalyst to change the physicians' mind if they were already leaning toward an agreement."

UH has seen its physician group grow from about 1,350 doctors in 2014 to about 2,100 today. Dr. Cliff Megerian, president of UH Physician Network, said about a third of this has come from the health system's hospital acquisitions; another third has been physicians joining from outside the region or state; and the final third is local independent physicians joining the system.

Right now, UH is talking with "a number" of different independent groups considering aligning with the system, which is becoming more common as the administrative burden for physicians grows "tremendously," Megerian said.

But short of actually joining the system, UH makes it possible for physicians to work with its network of doctors while remaining independent, most notably through its clinically integrated network. This network allows independent physicians to align with the system and participate in its accountable care organization contracts. In just two years, the clinically integrated network has grown to 2,800 independent physicians.

"UH is committed and has doubled down on the notion that we want to work and maintain independent physicians' livelihood," Megerian said. "We want to maintain their independence, but we want to also hopefully have them desire to use our system when they so see fit."

The Cleveland Clinic similarly offers ways for independent physicians to connect with the system without becoming employed doctors, such as through its own clinically integrated network. An ecosystem in which doctors have choices in how they practice, be that independent or employed, is important for meeting the different desires and goals of different physicians, said Dr. Brian Donley, the Clinic's chief of staff.

"I think if you just have one model of care, one model for physician participation, I think you limit yourself as a health care system to the opportunities to have a variety of skilled physicians be a part of your system that delivers outstanding care," he said.

Ware, the internist with Northshore Healthcare, said she believes more of her peers are considering independent practice, but haven't made the jump.

"I think the more that we can show that this is an option and a viable option for us as well as our patients, I think there will be more of an interest in it," she said. "I do think people are looking at it as an alternative."