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