Academic systems have a care distribution opportunity

Different purposes require different operating models

Academic and community hospitals serve fundamentally different purposes. Community hospitals typically provide high-volume care for common conditions and procedures, with success depending on access and the ability to deliver consistent services at an appropriate cost. AMCs operate within a different clinical and economic model. They care for a greater concentration of complex patients while supporting teaching and research missions, and their physicians may divide their time among clinical care, education, research, and administrative responsibilities.

According to Vizient data, tertiary and quaternary (T/Q) cases accounted for just 21% of inpatient discharges at AMCs between Oct. 1, 2024, and Sept. 30, 2025, but generated 47% of inpatient revenue. Vizient projects that T/Q procedures will grow 28% between 2026 and 2036, compared with a 4% decline in non-T/Q procedures. These trends reinforce the financial importance of preserving capacity at AMCs for the services that demand their specialized resources.

Those differences have implications for physician compensation and productivity expectations, capital allocation, and cost structures. Applying the academic model across the community network can make routine care unnecessarily expensive, while applying a community operating model to the academic enterprise can fail to account for the resources required to provide complex care and support the academic mission. Leaders therefore need to define distinct roles for academic and community facilities based on what each is best equipped to do.

Defining those roles starts with identifying which services benefit from concentration and which can be distributed. Highly complex procedures generally benefit from being concentrated where organizations can develop sufficient volume, clinical expertise, and supporting infrastructure. Take, for example, transplants: rather than dispersing these cases across multiple facilities, an academic system can and usually should concentrate them at its academic core. This builds the volume and expertise needed to sustain a high-quality program.

Routine care often benefits from being distributed across the community-focused parts of the system. Yet Vizient data show that AMCs continue to perform substantial volumes of common procedures, such as hernia repairs and carpal tunnel releases, that could be delivered in community settings. A screening colonoscopy generally does not require the infrastructure of an AMC; providing that service there consumes capacity in an expensive setting while potentially competing with complex cases for clinical resources.

These decisions should reflect clinical quality, patient needs, capacity, and economics rather than organizational history or physician preference. They should be made with the understanding that the appropriate setting for a patient can change over the course of treatment.

Build a two-way system

For academic systems, moving appropriate complex cases toward the AMC is usually the easier part. It takes more discipline to move patients back. Consider a patient who travels to the AMC for complex cancer surgery (e.g., a Whipple procedure for pancreatic and related cancers). Specialized follow-up may initially require the faculty oncology surgeon, but 12 months later, if the patient has recovered without complications, much of that care may be provided safely and conveniently closer to home.

Too often, that transition back to community care does not occur, and patients remain attached to the AMC indefinitely. Specialists accumulate panels of established patients requiring routine follow-up, limiting their ability to see new patients who need their expertise. Community physicians also lose opportunities to provide appropriate longitudinal care and maintain relationships with patients.

An effective academic-community system therefore needs patient movement in both directions: toward specialized resources when clinical needs warrant it and back toward community care when those resources are no longer necessary. Creating that movement requires system-level care navigation: a coordinated approach to determining where patients should receive care and managing their transitions across the enterprise.

Make decisions for the whole system

Managing care across the enterprise becomes more complex as the system grows. What worked when an organization consisted of an AMC and a couple of community hospitals becomes harder to sustain across a large network of hospitals, ambulatory facilities, and physician practices. The continued shift of procedures into ambulatory settings adds another dimension; health systems must determine whether services that can safely and efficiently be delivered outside the hospital should move into existing community facilities or dedicated ambulatory surgery centers.

Leadership needs to recognize the distinct roles of academic and community operations while maintaining accountability for system-level performance. To achieve this, some organizations have established separate academic and community divisions under common system leadership, acknowledging that the two require different operating approaches while remaining part of the same enterprise.

Clinical and administrative leaders also need performance expectations (including incentives) that reward appropriate care distribution across the enterprise, rather than maximizing volume or revenue within individual facilities. Such alignment can help translate strategy into consistent practice.

Making decisions for the enterprise as a whole can require difficult tradeoffs, including asking individual facilities or physician groups to give up volume or resources. Ultimately, an organization’s success depends on its willingness to make those choices even when they run counter to the interests of individual constituents.