Prisma Health—formed from the merger of Palmetto Health and Greenville Health System in mid-2017—is making big waves in the Columbia market: Prisma Health–Midlands is acquiring Providence Health/KershawHealth, which will make Columbia a two-system market. Health systems in the market already were consolidated because of the closing of Fairfield Memorial Hospital in Winnsboro and the acquisition of KershawHealth by Providence Health’s parent company, LifePoint Health, in late 2018. Prisma Health’s geographic and market share dominance may force Lexington Medical Center to expand its footprint beyond Lexington and Richland counties. Elsewhere, value-based contracting models mostly involve bonus payments with little risk, although dominant insurer BlueCross BlueShield of South Carolina runs a few bundled payment model pilots and has an extensive patient-centered medical home network in the market and state. BlueCross BlueShield has little incentive to promote payment reforms, but Prisma’s growing footprint could force change by offering more coordinated and successful ways to manage quality, efficiency, and costs.