vidual, as a member of a health insurance plan, and as a part of a community. This triple focus complicates the already intricate balancing act that characterizes patient care in the health professions schools. Not only do schools have to consider differences in individual patients' characteristics and manage possible conflicts between individual and community needs, they must also take into account differences in the objectives and policies of the health plans that increasingly manage or arrange for services for employer, governmental, or other sponsors. Sometimes the interests of these health plans closely parallel those of their individual members, but they may at other times conflict (e.g., when plans restrict member's choice of provider or impose bureaucratic hurdles before care can be provided). When they do, the health care provider can be caught in the middle. As discussed in this chapter, the provider's position is even more difficult if it is also an academic institution with educational and research missions.

Further confounding the patient care responsibilities of the dental school are the varied views of these responsibilities by different individuals and groups. To indigent patients, the student dental clinic may be the only source of care. Similarly, to politicians in a state with public or private state-related dental schools, the clinic may be a vehicle for meeting the needs of the underserved. The community dentist may view a faculty practice plan as a good place to refer complicated patients such as those with AIDS, infectious tuberculosis, or severe behavioral problems. The community dentist might also view the plan and the student clinic as competitors. To the administration of a university or academic health center, the outpatient clinics of a dental school may be a mystery—different from any component of the medical school and in chronic need of subsidy. These varied perspectives challenge dental schools to clearly articulate the value and requirements of their patient care mission.

Such an articulation of the contribution of dental schools to the parent institutions and communities is also important because, even if substantially restructured, patient care in dental schools will include some inefficiencies associated with the educational process. Student clinics are unlikely to be able to cover their full costs through patient fees. Moreover, many educators expect that dental schools' economic advantage—low cost or "free" care for patients without access to the private practice system— will diminish as dental insurers organize network health plans and demand price and other changes from community practitioners. Thus, dental educators with the help of others in the dental community must make the case for public support of the educa-



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