Elsewhere in this issue, Welch and Bindman present research demonstrating that academic health centers (AHCs) continue to disproportionately comprise specialists and subspecialist faculty physicians compared with community-based physician groups. This workforce composition has served AHCs well through the years—specialists fuel the clinical engine of the major tertiary and quaternary missions of AHCs, and they also dominate much of the clinical and translational research enterprise. AHCs are not alone—less than one-third of U.S. physicians practice primary care. However, health reform has prompted many health systems to reconsider this configuration. Payers, employers, and policy makers are shifting away from fee-for-service toward value-based care. Large community-based physician groups and their parent health systems appear to be far ahead of AHCs with a more balanced physician workforce. Many are leveraging their emphasis on primary care to participate in population health initiatives, such as accountable care organizations, and some own their own health plans. These approaches largely assume some element of financial risk and require both a more balanced workforce and an infrastructure to accommodate the management of covered lives. It remains to be seen whether AHCs will reconsider their own physician specialty composition to emphasize primary care—and, if they do, whether the traditional academic model, or a more community-based approach, will prevail.