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Are We Failing at Integration Strategy, or Infrastructure?
Are We Failing at Integration Strategy, or Infrastructure?
By Jerry Penso, MD, MBA
March 5, 2026
Lately, I’ve been spending time with health system leaders—visiting organizations, sitting in on leadership discussions, listening beyond the strategy decks. What’s striking isn’t that integration is difficult; everyone knows that. It’s how rarely we’re building the basic infrastructure integration requires—the governance structures, the decision-making clarity, the shared metrics, the actual accountability.
We’re so busy operating medical groups and hospitals, delivering care every day and fighting fires, that the foundational work doesn’t happen.
"We’re Still Operating Like a Federation of Independent States"
That line came from a medical group leader whose system has gone through multiple acquisitions in recent years. They’ve got thousands of providers across multiple hospitals, yet “there’s still no real sense that we’re on the same side.”
The symptoms are familiar: EHR workflows that differ years after go-live. Strategic plans “coordinated” at the end rather than built together. Service lines that stay regional because no one wants to relinquish local control.
But here’s what struck me: The real issue isn’t just communication—it’s structure. Who actually has decision-making authority? What metrics are we measuring? Which initiatives are fully implemented versus half-measures that create more complexity? In some systems, multiple entities still employ physicians separately. The structure does not support integration.
At one system I visited recently, the leadership told me afterward that our meeting was the first time many of their medical group leaders had ever sat down with system executives to discuss integration. First time. The system had acquired multiple practices over several years, but had never created regular forums for these conversations. They weren’t avoiding integration—they simply hadn’t built the infrastructure for it to happen.
"Culture Should Be a Line Item on Your Budget"
One CMO put it bluntly: “Culture should be a line item on the budget. You should be able to see what money is being spent on it.”
His system invested roughly $1 million annually in a Leadership Institute that has trained more than 900 leaders—and kept it going through the pandemic. Why? Because shared culture doesn’t emerge organically. It requires sustained, visible investment. His point wasn’t just about physician culture—it was about system leadership demonstrating commitment through tangible budget allocation.
Other systems are investing in ambient listening technology for thousands of clinicians, dedicating staff to reduce provider message burden by 80%, or instituting systemwide well-being offices.
The common thread isn’t the specific investment—it’s the intentionality. They’ve carved out the budget and time for the integration work, beyond just the integration announcement.
"How Do We Give Providers a Voice Outside the Traditional Hierarchy?"
A CMIO who commented on my last post captured it well: Health systems call themselves integrated, but “planning, capital, compensation, care transitions, and technology still run as separate kingdoms.”
From the clinical leadership seat, the fragmentation is obvious. Planning happens with no clinical authority. Capital gets deployed without workflow consideration. Care transitions leak patients. Compensation structures hinder access. Technology rolls out systemwide with minimal governance.
The question multiple leaders raised: How do we create governance structures where physicians have real authority—not just advisory roles? How do we build feedback loops that actually change decisions, not just check the “physician input” box?
This isn’t about satisfaction. It’s about execution. You can’t deliver on integration promises if clinical leaders don’t have the authority to align operations.
What Actually Has to Happen
Here’s what I keep hearing from systems that are making progress: Integration requires building real infrastructure, not just declaring integration happened.
That means regular working sessions—not formal governance meetings where decisions get ratified, but actual working sessions where hospital and medical group leadership tackle standardization together. Where you have uncomfortable conversations about eliminating duplication. Where you define what “integrated” means operationally for your specific organization.
It means governance structures with clear authority and accountability that cross hospital and medical group boundaries. Metrics that measure system performance, not just entity performance. Decision-making bodies where operational and clinical leaders have genuine authority, not symbolic seats.
And it requires peer learning—not from consultants selling frameworks or vendors pitching solutions, but from other executives who have actually done this work, leaders willing to share candidly what worked, what failed, and what they’d approach differently next time.
The challenge is creating space for both kinds of work: the internal infrastructure building and the external peer learning. Both take time. Both require intentional investment. Both get squeezed out by daily operations.
That’s the pattern I keep seeing. Systems know what needs to happen. The question is whether they’ll actually commit the time and resources to make it happen—or keep hoping integration will somehow emerge on its own.
Where Are You?
Which of these challenges resonates most with your experience? Where have you actually built infrastructure that’s working? Where are you still figuring out the right approach?
Jerry Penso, MD, MBA, is president and CEO of AMGA.
Originally published on LinkedIn.
