The threat to the United States' Academic Health Centers (AHCs) has been reported for the past decade, signified most importantly by the decrease in the perceived value of patient care delivered and a significant reduction in direct payments to physicians in AHCs. These reductions have required AHCs to become more efficient and increased pressures to become more productive in both patient care and research. The U.S. healthcare system continues to evolve in response to these challenges and the additional pressures of increasing costs and the increasing numbers of uninsured. Ten trends for the next decade are evident: 1) more patients, 2) more technology, 3) more information, 4) the patient as the ultimate consumer, 5) development of a different delivery model, 6) innovation driven by competition, 7) increasing costs, 8) increasing numbers of uninsured, 9) less pay for providers, and 10) the continued need for a new healthcare system. In response to these trends, AHCs will have to continue to improve efficiency by increasing cooperation between researchers, clinicians, and educators while demonstrating how they are "different" and "better" than the competition.The AHC has the tools and the personnel not only to improve patient care processes but also to understand how to decrease costs while maintaining quality. AHCs also have the size and expertise to establish control over geographic market share with services not available elsewhere. Such programs must be able to evolve and respond to market pressures, and the AHC must be an engine of innovation, continuously regenerating new knowledge and programs with "Centers of Excellence" and appropriate industry partnerships. Such progress is driven by better communication and greater sharing of information and collaboration at all levels, including building better physician referral networks. These accomplishments, driven by technology, will allow AHCs to improve quality of care and increase efficiency even under the increasing burden of patients and uninsured. This will position AHCs as the most important advocates and lead players in the development of an improved national healthcare system.