Rapid population growth is pushing Nashville’s integrated delivery networks outside the urban Davidson County core, especially Rutherford County (40 minutes southeast of metro Nashville), where Ascension Saint Thomas and Vanderbilt University Medical Center both filed certificates of need for new hospitals. While only Ascension was granted the CON, VUMC’s recent merger and acquisition activity—which brought three new facilities into the IDN in January 2021—suggests the academic medical center is evolving into a regional hub with spokes both in and outside the Nashville market. This strategy could render VUMC a more attractive partner on payer contracts but will do little to impact local market share, unless VUMC fleshes out additional inpatient services inside Nashville’s borders. TriStar, which is acquiring the 109-bed NorthCrest Medical Center in Springfield, is positioned to remain the market leader for years to come, especially as it pursues higher-acuity care across its network. Overall, payer and provider lines may continue to blur as BlueCross BlueShield of Tennessee explores its new primary-care centers (a partnership with Sanitas) and Ascension enrolls members in a new joint-venture Medicare Advantage plan with Centene (an initiative that started in Ascension’s other markets of Florida, Illinois and Kansas). While we expect prescription drug utilization to rise in the post-COVID era from newly diagnosed individuals, CMS’ recent approval of Tennessee’s proposed Medicaid block grants threatens the status of branded drugs on the Medicaid formulary.