Current challenges to academic health centers.

Academic health centers (AHCs) have long been the exemplars of medicine in the United States. They produce “breakthrough” research, pioneer new diagnostic and therapeutic interventions, and train the best and brightest future physicians with emphasis on specialists and subspecialists. Today, they face a perilous future because the health care economic system that supports this enterprise is fading away; what Enthoven has called “cost unconscious” third-party payment for care is being transformed into “value purchasing.”1 The challenges currently facing AHCs are more complex and more pervasive than any previously observed by faculty physicians, administrators, and boards of trustees. Unless met promptly and thoroughly, AHCs may lose their place at the apex of US health care. The challenges arise first and foremost from efforts of government and business to control the cost of care. This challenge will require AHCs to change the way they organize, price, and deliver care, with significant consequences for their research and education missions. Complicating the situation are changes in the US patient population—more ambulatory and less inpatient, more chronic and less acute illness, and more elderly persons, with different symp-