The Endgame, Part I: Three Futures

After mapping 30 organizational models, I see three possible destinations. Only one of them works.

I’ve spent the last several months mapping how U.S. healthcare is actually organized. Thirty models across five layers, from the solo family physician to the $370 billion vertical empire of UnitedHealth Group.

The throughline I didn’t fully see until I was done: every organizational model in American healthcare was created to solve a coordination failure. And every one of them, in solving it, created a new boundary that produced a different coordination failure.

Physicians couldn’t negotiate alone, so they formed IPAs. The IPA solved the negotiating problem and created a data fragmentation problem. Hospitals and physicians needed unified managed-care contracts, so they built PHOs. The PHO solved the contracting problem but didn’t produce real clinical integration. Independent providers needed value-based contracts without merging, so they invented the CIN. The CIN solved the participation problem but created a governance problem.

Every solution works. Every solution leaves a gap. That gap creates the next model. It’s been running for forty years.

So where does this end? I see three possible futures. All three are already underway.

Future 1: Convergence Through Ownership

Optum employs or affiliates with roughly 90,000 physicians. CVS Health owns Aetna, Oak Street Health, Signify Health, MinuteClinic, and Caremark. Humana owns CenterWell clinics, home health, and pharmacy.

Let me be direct about this one: what these companies are doing is not integration. It’s annexation. They’re buying the pieces of the healthcare value chain one acquisition at a time and calling it coordination.

Inside the walls, it works. An Optum physician referring to an Optum specialist, with the patient insured by UnitedHealthcare, creates seamless coordination. Data flows. Incentives align.

But the math breaks at the edges. Even Optum, with 90,000 physicians, covers roughly 9% of the practicing workforce. The U.S. has over a million doctors. The solo family physician in rural Ohio isn’t getting acquired. The critical access hospital that’s the only facility for 50 miles isn’t joining Optum’s network. Vertical integration solves coordination for the patients inside the fortress and leaves everyone else with the same fragmentation they’ve always had.

And there’s a regulatory ceiling that’s getting lower every year. The FTC sued US Anesthesia Partners. The DOJ is blocking hospital mergers. State AGs are investigating PE-backed rollups. There is a political limit to how much healthcare a handful of corporations can own.

I respect the operational ambition. I don’t think it scales to a country of 330 million people.

Future 2: Federated Networks With Shared Risk

CINs, ACOs, and the enablement platforms that support independent physicians represent a more democratic alternative. Don’t merge. Align. Share data, follow common protocols, split the savings.

About 480 MSSP ACOs now cover 11 million Medicare beneficiaries. Clinically integrated networks let independent physicians participate in value-based contracts while keeping their practices. Enablement platforms provide the analytics and care management that small practices can’t build alone.

I have more sympathy for this future than the first one. It preserves physician independence. It doesn’t require massive capital. It works with existing structures.

But I’ve watched enough federated networks up close to know their failure mode. The physician champion who drove CIN participation retires and nobody replaces the energy. The health system anchor gets a new CEO who decides employed physician growth matters more than network maintenance. The shared savings pool has one bad year and three practices quietly disengage. I’ve seen a thriving CIN hollow out in 18 months after a single leadership change.

Federated networks are elegant when they work. They’re fragile by design, because they depend on sustained voluntary commitment from parties with different economics and different priorities.

Future 3: Platform-Mediated Coordination

This future doesn’t have a single company building it yet. It’s an architectural pattern emerging at the intersection of foundation models, ambient computing, and healthcare’s slow progress on interoperability.

The theory: if no entity can see the full patient picture across all 30 organizational models, the solution isn’t a bigger entity or a better network. It’s an intelligence layer that sits between the patient and the system. One that persists across care transitions, synthesizes data from multiple sources, and acts on behalf of the patient regardless of which organizational model they’re inside at any given moment.

Not an entity. Not a network. A layer.

It doesn’t require ownership, formal agreements, or physicians giving up independence. It works with the existing stack. And the technology to build it became viable at a useful quality level approximately 18 months ago.

The counterargument is earned: healthcare is littered with the corpses of technology platforms that were going to fix coordination. Google Health. Microsoft HealthVault. Haven. The pattern is consistent: technology overlaid on the system without changing incentives is a dashboard nobody uses.

This might be different. Or it might be Google Health with better language models. I’ll make the case for why I think it’s different, but I owe the graveyard its respect.

Where I Stand

I don’t think Future 1 gets us there. It concentrates power without reaching the majority of patients and providers who will never be inside a conglomerate’s walls.

I don’t think Future 2 gets us there alone. It’s the right instinct — align without owning — but the governance overhead and fragility are real constraints, not solvable objections.

Future 3 is the only architecture I see that scales without consolidation, works for independent providers, and puts the patient at the center. But it only works if it’s built on a payment model that rewards health over volume. The intelligence layer without value-based economics is an app. Value-based economics without the intelligence layer is a spreadsheet.

The endgame isn’t one of these futures. It’s the interaction between them.

But if the answer involves a platform, the immediate question is: why haven’t the entities that already exist just built one?