The pendulum from independent to system-owned practices may be swinging begrudgingly and incrementally toward independence again. We’re in the midst of the 2nd generation integrated model. The 1990s brought us the first attempt, with health systems on a feeding frenzy to be the biggest and (failingly) the best. Instead, health systems lost substantial financial resources and either closed or sold off practices for pennies on the dollar. The recent second generation attempt places more risk on physicians, though it is clear once again that hospitals and medical practices require different business models. And in many cases, hospitals are not prepared to effectively manage physicians. The compromise of clinical integration . . . somewhat of a midpoint between fully autonomous and system ownership . . . may be the preferred result in an atmosphere of deep dive analytics driving value-based and risk-based contracts. There is an evolution of physicians negotiating with health care systems rather than directly with insurers for their piece of the revenue pie.