Introduction Few can argue with the assumptions underlying the centrality of physician integration. Strange Bedfellows or a Marriage Made in Heaven? is a well-conceived research effort where multiple data sources provide a wide range of exploratory analyses. In this study, physician integration refers specifically to the economic alignment of physicians with organizations. The work focuses on marketbased arrangements for hospital and system organizational linkages with physicians. The organizational environments and markets are analyzed as structural variables related to alignment. The process variables consist of building trust, placing physicians in management and governance, and developing physician leadership. This is a good research contribution with results and implications of fundamental importance to improving organizational effectiveness in managed care settings. In thinking about the authors' research, I am reminded of Rashi Fein, the distinguished Harvard health economist, who said that policy makers and health analysts do not seem to understand that we all live in a society rather than merely an economy (Fein 1974). Dr. Zuckerman et al.'s research involving economic markets and social processes relates to the fact that economic strategies and policies are best understood if considered in the context of social conditions and policies. Dr. Zuckerman et al. point out that social processes at the organizational level can facilitate or, in other cases, impede the successful integration of physicians. I will group my comments stemming from this research into three areas: 1. the importance of process specification in the managed care marketplace; 2. social forces and interests that influence learning in organizations attempting physician integration; and 3. the importance of understanding an organization's culture early in the planning for such strategic initiatives. Managed Care Process Model It is instructive to look at the range of processes that might force the integration of physician and administrator teams. Figure 1 is a framework that describes many of the processes that need to be managed as managed care market penetration increases. As the processes move clockwise, managed care market penetration increases, and physicians are required to work more closely with administrators to determine and manage the relationship between low cost and high quality. The set of processes on the right side of the model focuses on systems intended to support the analysis of cost reduction efforts by administrators. These processes seem to be the drivers of organizational performance in the condition of low market penetration of managed care. This roughly corresponds to Stages 1 and 2 of the market stages identified by the authors. In this situation, the support systems are limited to cost identification and management. There seems to be relatively little necessity for forced or required interaction in order to reduce costs or for sophisticated information systems permitting the analysis of both costs and quality. As managed care penetration increases, however, the mutual dependence of administrators and physicians increases, and they are required to interact when documenting cost/quality relationships that demonstrate value. These forced interactions require teamwork based on the performance of the distinct competencies of physicians and administrators. At the same time, the support systems required to inform decision making in these interactions is very sophisticated and complicated. These new systems require information that is comprehensive enough to analyze both cost and quality dimensions. These expensive healthcare information systems are few in number, and for the most part do not permit comparisons with external organizations for purposes of benchmarking. This framework suggests that physicians and administrators are forced to work together in new and complicated ways, and the boundaries of both professional knowledge and the domains of organizational influence can become blurred. …