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Independence Blue Cross has negotiated several multiyear contracts with Philadelphia's dominant health systems and specialty physician groups. IBC's partnership with the University of Pennsylvania Health System demonstrates the highest level of risk, putting even the system’s readmissions at risk. Meanwhile, Jefferson Health’s close relationship with Main Line Health is another driver of payment reform. While there is low consolidation in the health system sector, smaller hospitals are partnering with the biggest integrated deliery networks to offer local access to top-notch specialists (cardiology, orthopedics, and cancer). The market also takes on more clinical trials for rare diseases with the creation of a new consortium, an opening for orphan drugs. Risk-sharing will grow in 2019, although hospitals will feel pressure to consolidate to handle funding squeezes. IBC and Penn Medicine will emerge in the short-term as the most affordable option, but Jefferson Health will remain competitive.