In response to opportunities and threats in their environments, academic health centers (AHCs) are making important changes in their structure. Several AHCs have legally separated their university hospital from the university. In contrast, other AHCs are linking the university hospital more closely to the medical school by concentrating authority for key decisions in the office of an AHC executive. This article draws from a national study of AHCs and examines the advantages and disadvantages of such changes in AHC structure. An important reason for these changes is maximizing revenues from patient care; an important consequence is the increased salience of patient care among the multiple purposes of AHCs.