As the United States struggles to redefine the cost and delivery of health services, health care executives struggle to identify the most appropriate strategic agenda. With the model for the market evolution of health care becoming an accepted industry paradigm, it serves as an excellent medium for discussing the potential challenges an institution may face as its market progresses toward managed competition. Four cities, each at a different stage of evolution, are discussed in an effort to help health care executives in craft strategies for sustaining their institution's viability.