The rapidly changing healthcare environment is driving strategic reshuffling and competitive responses that will permanently alter the operational landscape for all healthcare organizations. Community-based healthcare providers across the country in particular are rapidly moving to large, vertically integrated healthcare systems. As these organizations grow and develop, they are becoming closed systems of care and developing tertiary and quaternary care capabilities. In addition, these providers are reducing, and eventually eliminating all but a trickle of, the flow of specialized referrals to academic medical centers (AMCs). At the same time, the focus of available research funding is shifting from basic research toward clinical, translational, population health, and comparative effectiveness platforms. These reductions in funding and the loss of referrals threaten the sustainability of AMCs' research and teaching missions.