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Consolidated Sacramento health systems are largely operating as integrated delivery networks, with the three dominant systems accepting capitation and functioning as payers themselves, each with its own HMO. The growth of Sutter Health’s new HMO has helped propel it just above Dignity Health in market share thanks to the health plan funneling new patients into its doors. As the market’s integrated delivery networks continue to become more sophisticated, watch for them to begin asserting leverage in 2018 over clinical decisions that impact formularies and plan design.