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Consolidation has reached a zenith in Sacramento. Competition among health systems is fairly evenly distributed among the three leaders, but Dignity Health, which is working on alignment with Denver-based Catholic Health Initiatives, is readying to pull ahead of the pack. A Dignity-CHI marriage will, of course, first have to clear regulatory hurdles. In integrated market, pharmaceutical acquisition is on the verge of changing as the providers are taking capitated risks and becoming payers themselves. To that end, we expect drug acquisition discussions will shift from “what do the traditional payers want?” to “what do the providers want?” As these consolidated health systems become more sophisticated and able to make drug purchasing decisions, watch for them to begin asserting leverage over clinical decisions that impact formularies and plan design.