We've listened to President Obama. We've studied the continued slide in employment and the rise in public anxiety over health costs. We've also interviewed a score of hospital CEOs in 20 markets across the country. Most of you are hopeful but nervous about how you, your board, and physician leaders will master challenges in the current economic climate.

1. The anticipated cash-flow squeeze at end of 2009 from patients who move off COBRA and become "slow or no pay" users of your emergency room and owned physician practices

2. Delayed capital investments that frustrate your initiatives to enhance service and technology options for your patients and their doctors

3. Workforce morale malaise from fear of layoffs, and the resulting erosion of progress in service excellence

4. A new wave of physicians pushing for practice acquisition

5. Increased stakeholder skepticism about board oversight of compensation for physician leaders and executives