Healthcare in Grand Rapids is consolidating around Spectrum Health, Mercy Health, and Metro Health. Dominant insurer Blue Cross Blue Shield of Michigan continues to drive payment reform. The carrier operates accountable care arrangements with Grand Rapids’ major providers and will begin mandating downside risk in 2021 for participants in its new Blueprint for Affordability model. Independent physicians will feel more pressure to align with a major health system as arrangements like Blueprint for Affordability become more common. Providers are also beginning to undercut the dominance of large payers like BCBSM, contracting directly with area employers to provide care.