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Massachusetts has begun shifting most of its managed care-eligible members into risk-bearing accountable care organizations, increasing alignment between payers and providers. The model gives providers the option to contract with insurers or directly with MassHealth, which could diminish the role of MCOs. In opposition to the rise of integrated delivery networks, OptumHealth, a subsidiary of UnitedHealth Group, has acquired Reliant Medical Group, Worcester’s largest independent physician group. Insurers are turning their attention to pharmacy expenses, with BlueCross Blue Shield of Massachusetts, Tufts Health, and Harvard Pilgrim naming prescription drug spending as a top priority for reducing overall expenditures. Look for new payment reform initiatives to drive higher levels of integration as health systems, physician groups, and insurers develop strategies to address medical and pharmaceutical cost growth.