Hospital linkages between quality outcomes and finances are increasing, as pay-for-performance programs increase. Hospitals face very real challenges in working with physicians that directly control both resource consumption and quality outcomes. Effective strategies for integration between hospitals and their medical staff must be achieved to successfully address these issues. One of the best ways to achieve goal congruency between hospitals and medical staff is through the development and implementation of a Management Service Agreements (MSA). Explore the use of MSAs as one successful methodology to attain hospital/physician alignment. Analyze the overall methodology and approaches to developing an MSA. Through case study, learn examples of successful MSAs and ongoing results.