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Cleveland's largest and most innovative delivery systems are contuing to exert their influence over the market through payer-provider partnerships, major footprint expansion projects, and even a potential merger. The integrated delivery networks, with their huge clinically integrated physican groups, are positioned to drive further into payment reform and to grow larger through affiliations and expansions that will make Cleveland's status as a major healthcare hub even stronger. Health plans are holding their own, for now, in a favorable econmic environment, and one prominent insurer has even elected to re-enter the exchange after sitting out last year.