The Boston healthcare market is consolidating so rapidly it resembles a game of musical chairs. No health system in this large and lucrative market wants to be the last one standing, without partners, without affiliations, without the vital referral patterns that keep their flagship urban teaching hospitals beds filled. Nailing down these critical relationships will cushion the impact of shared risk as global payment contracting takes over as the dominant model in Massachusetts.

To survive in the changing world, urban systems are pouncing on vulnerable suburban hospitals, but consolidation takes more forms than simple merger and acquisition. Given that any one of the hospitals in the market can have multiple clinical affiliations with urban academic medical centers, the result is a bewildering tangle of referral patterns that are still in flux.

In this game, the bigger the player, the harder they play. And the harder they play, the more state regulators are tempted to blow penalty whistles.

Nobody plays harder than Harvard-affiliated Partners HealthCare. Partners is already the biggest player in the market, one of the biggest in the country, with the market's No. 1 and No. 2 ranked hospitals Massachusetts General and Brigham and Women's. It accounts for nearly a third of all health plan reimbursements, more than the next two health systems combined. It's so big, so powerful, that it has drawn the ire of Attorney General Martha Coakley, who issued a report in 2012 laying the blame for healthcare cost inflation on its doorstep. Now Coakley is pondering whether to allow Partners to expand with strategic acquisitions of South Shore Hospital in Boston's southern suburbs and Hallmark Healthcare on the North Shore. A newly formed state commission has already recommended the acquisitions be blocked.

While Partners is immobilized by red tape, its closest competitor, Beth Israel Deaconess Medical Center, also a Harvard teaching hospital, is rapidly nailing down partners and acquiring small hospitals. Beth Israel Deaconess added Jordan Hospital on the South Shore in 2013 and has forged tight clinical integration bonds with smaller health systems, including Cambridge Health Alliance and Signature Health.

The third-largest system in the market, for-profit Steward Health Care System, initially looked well on its way to locking up a system of value-based community hospitals that could form the basis for profitable narrow networks and ACOs. Steward, however, has had a bad run in the great game over the past year, hampered by labor disputes with nurses, credit rating downgrades and poor scores on its Pioneer ACO results. Beth Israel also swiped back a highly regarded doctors group, Whittier Independent Practice Association, as part of Anna Jacques Hospital's  decision to join Beth Israel's new ACO. Steward had nabbed Whittier from Beth Israel just two years ago

Tufts Medical Center, much smaller in terms of beds and annual discharges than these three, is also an academic system for Tufts University's medical school. It has a far-flung and highly regarded physicians groups, the New England Quality Care Alliance.  It is also trying to play the great consolidation game with its bigger rivals.

Tufts has some advantages, including a reputation for value and a highly regarded pediatric hospital, the Floating Hospital for Children. Unfortunately, it too has had a run of bad luck. Beth Israel has scooped up some of its clinical affiliations; in addition, an attempt to create a larger system with MetroWest Medical Center in Framingham, along with Saint Vincent Medical Center in Worcester, formerly owned by Vanguard Health Systems, seems stalled by Tenet's purchase of Vanguard. Tufts has less cash to compete with the bigger systems and is left scurrying for smaller chairs as the music speeds up.

So the band plays on in Boston. Who will be left without a safe seat when the music stops. That's anyone's guess, but the only one at this point whose seat seems at least momentarily secure is Beth Israel Deaconess.

Follow Lyda Phillips on Twitter @LydaPhillipsDRG

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