Contractual Health-System Alliances Expand Governance and Antitrust Exposure Without Changing Ownership

Health systems are increasingly using purchasing alliances, clinical partnerships, shared services, and other contractual arrangements instead of mergers. These structures can still create board-level risk through exclusivity, shared economics, clinical-integration obligations, community commitments, vendor dependence, antitrust boundaries, accountability gaps, and difficult exit rights. Montana purchasing activity illustrates why diligence must examine control and operational consequences, not ownership alone.