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The Columbia market still relies on fee-for-service payment models, and health systems are expanding their facilities and acquiring more medical practices to drive patient volume and perform more profitable procedures, particularly for cardiac, neurological, orthopedic, and diabetic conditions. The number of insured patients able to pay for expensive medical care is falling, however, and areas of the market are embracing population health. Value-based contracting models mostly involve bonus payments with little risk. With many signs pointing to a higher uninsured rate in 2019, Columbia will see more narrow network and high-deductible health plans with lower premiums. BlueCross BlueShield of South Carolina has had little incentive to promote payment reforms, but the state’s largest health systems are building partnerships that could jumpstart change by offering more coordinated and successful ways to manage quality, efficiency, and costs.