put academic health centers at a disadvantage because of their costly characteristics including clinical teaching and research, extensive tertiary services, and care for indigent patients turned away elsewhere. Many centers also have a dearth of primary care practitioners and facilities to serve the day-to-day needs of health plan members. To the extent that it favors mergers and multihospital systems, the competitive environment poses another problem because many academic health centers are constrained in their decisions by their university affiliations and public sponsorship. Proposals to revamp Medicare payments for graduate medical education—a major source of income for health centers—and to institute residency quotas also threaten the financial health and operating arrangements of academic health centers. (Some of these problems are discussed further in Chapter 7.)

The position of the dental school needs, however, to be distinguished from that of the university hospital or the medical school in certain respects. Rather than relying on a separate hospital as medical schools do, each school operates its own outpatient dental "hospital" in the form of a student clinic. These outpatient clinics do not receive the kind of direct and indirect educational payments from Medicare that teaching hospitals receive. Within the dental school, the imbalance between general and specialist care and faculty is substantially less than in the medical school and medical center hospital. In addition, although the spread of dental insurance has allowed more patients to pay for care from private practitioners, the high cost-sharing requirements of many dental plans continue to make the dental school clinic attractive to lower-income patients.

Today, some dental schools have a backlog of patients, and patients may wait weeks for an appointment (Tunnicliff, 1994). At the same time, these schools and others may worry about a shortage of certain types of patients for their student clinics. One consequence of the reduction in caries among children has, for some schools, been an insufficient number of patients with simple caries. Students may thus face complex patients earlier than they would have in the past, another argument for more faculty involvement in patient care.

Where schools face shortages of "teaching" patients, they may try to be more patient oriented to attract those in need of care. This may be difficult. The efficiency, quality, and accountability deficiencies described in this chapter are not easily overcome, especially when the resources constraints make it difficult to upgrade facilities and staffing. In addition, efforts by dental schools

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