13 years ago at Columbia University Mailman School of Public Health, my capstone paper was titled “Highmark’s Journey from Insurer to Provider.” It analyzed how Highmark Health tried to challenge UPMC dominance by acquiring hospitals, physicians, land, and building a vertically integrated delivery system.

Looking back, some ideas still feel relevant. Others… not so much.

A few takeaways from my 2012 thinking:

• Vertical integration was inevitable but owning assets doesn’t guarantee coordinated care or physician alignment.
• I believed outpatient sites, physician groups, and land strategy would matter more than hospital towers. That still holds true.
• I underestimated how hard it is for a payer to operate like a provider. Culture, tech, governance, and physician trust aren’t bolt-ons.
• I even suggested building a medical school with Carnegie Mellon University to solve the physician pipeline and innovation gap. Bold? Unrealistic? Maybe both. We now see Duquesne University executing on this vision.

Questions I’m still wrestling with in 2025:

• What’s the minimum level of payer-provider integration needed to actually lower cost and improve access?
• Is acquiring distressed systems, net new building worth the execution risk vs. enabling high-performing independents? Should facilities constitute 80% percent or more of carrier reimbursement? What currently creates the wrong incentives that must be addressed?
• Does community trust still drive healthcare strategy or has analytics and steerage replaced it?