When New Hyde Park, N.Y.-based Northwell Health moved into Westchester County in 2016, acquiring two hospitals and two medical groups, it absorbed them into the same centralized operating model that governed everything else. What the system learned from that experience would eventually reshape how it approaches growth.
Physicians were not being heard, practices were not thriving and hospital stakeholders felt disengaged, Northwell COO Kevin Beiner told Becker’s.
“They felt like we had sort of put our sign on the side of the building and disappeared,” he said. “That’s when leadership did the soul searching to say, ‘Maybe we’re a little too big for this model.’ It wasn’t until we hit our friction points that we reevaluated it.”
What emerged became the framework guiding its integration of Danbury, Conn.-based Nuvance Health, the seven-hospital system it merged with in May 2025 to create a $22.6 billion, 28-hospital system.
Northwell now organizes its operations across four markets, each with its own president, lead physician, lead nurse and finance officer. A centralized C-suite sets strategy, culture and clinical standards across the enterprise. Horizontal service lines hold a single quality standard across all locations. The architecture is built around one guiding principle, Mr. Beiner said.
“It’s about getting the decision-making authority as close to the front line as possible,” he said.
He described the stakes of that principle in terms that go beyond internal management. The scale that attracts hospitals to larger systems can feel alienating to the patients and physicians those hospitals are meant to serve.
“It could be frightening for a patient in a community, and sometimes even a physician in a community, to think, ‘Wow, now I’m a part of being cared for in this multibillion-dollar, multistate corporation,'” Mr. Beiner said. “Rather, we try to behave as locally as possible.”
The legacy Nuvance hospitals operate as Northwell’s Northern Market. Mr. Beiner said the system is still assessing how patients in those communities prefer to seek care before finalizing the market’s permanent structure.
As the model matures, Mr. Beiner said his focus has shifted to preventing bureaucracy from accumulating inside the markets themselves. His test for whether the structure is working is a straightforward one.
“Can people at the front line have the agency to make decisions that they need to make to do the right thing for the patient?” he said. “If they can, we’re in good shape. If we can’t, we need a little bit of a refresher.”
Northwell’s evolution reflects a challenge that several major health systems are now navigating simultaneously. A wave of large-scale combinations that have closed or are pending regulatory approval shows systems reaching for governance solutions that vary in form but share a common priority: The community hospitals need visible, local accountability.
Philadelphia-based Jefferson Health and Allentown, Pa.-based Lehigh Valley Health Network merged in August 2024, creating a 32-hospital system with more than 700 care sites and 65,000 employees. Rather than consolidate leadership under a single existing structure, the combined enterprise drew its team from both organizations. Jefferson CEO Joseph Cacchione, MD, retained his role at the enterprise level. Brian Nester, DO, who had led LVHN, became executive vice president and COO of the Jefferson enterprise while also continuing as president of the legacy LVHN, maintaining leadership continuity for the communities LVHN had long served.
Sacramento, Calif.-based Sutter Health and Minneapolis-based Allina Health have proposed a transaction that would form a 39-hospital system. Under the plan, Allina would become a division of Sutter while retaining its board, its brand and its regional headquarters. Warner Thomas would serve as president and CEO of the combined organization, with Lisa Shannon continuing as president and CEO of Allina.
Charlotte, N.C.-based Atrium Health and Raleigh, N.C.-based WakeMed have also proposed combining into one system. The structure is designed to preserve WakeMed’s local voice while expanding what it can achieve for the community, an Atrium Health spokesperson told Becker’s. WakeMed President Donald Gintzig would continue in his role and be integrated into Atrium Health’s leadership, while WakeMed’s board of directors — the majority of whose members are appointed by the Wake County Board of Commissioners — would retain its current oversight authority. Advocate Health, which includes Atrium Health, will continue to be led by CEO Eugene Woods.
“This structure keeps decision-making rooted in the community WakeMed has served for more than 65 years, while also giving WakeMed access to Atrium Health’s expertise, scale and resources,” the spokesperson said. “The goal is to strengthen local leadership, not replace it.”
Mr. Beiner said he expects the pace of M&A activity to continue, with more hospitals seeking to join larger systems in bigger groups than has historically been common. The challenge, he said, is ensuring that growth does not outpace the governance structures built to manage it.
“It’s easy to think if we had another few hospitals, we can just run it the way we used to run it. It’s not a good enough answer anymore,” Mr. Beiner said. “We have to make the big feel small, and if we don’t make the big feel small, we’re not gonna win. And at the end of the day, it’s about providing care to patients and communities.”
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