Reflections on the National Dialogue for Healthcare Innovation and the Ongoing Struggle to Define Value in Healthcare

By Neel Shah, MD, MPP

 NeelThis month, I had the opportunity to sit at the table with some of the nation’s top thought leaders. We convened at the Newseum in Washington, DC, for the Healthcare Leadership Council’s National Dialogue for Healthcare Innovation; it was like a health policy nerd red carpet. Center for Medicare Director Sean Cavanaugh was there. Leapfrog Group CEO Leah Binder was there. America’s favorite bioethicist–oncologist–provocateur Zeke Emanuel was there. The chief executives of providers, payers, pharmaceutical companies, government agencies—all there. And what were they there to do? Define “value” in health care.


In 2015.

Don’t get me wrong. Everyone there, including myself, felt this was a worthy goal. What is lamentable is that it remains such a struggle to get this done—particularly in an era where the Internet has made transparency ubiquitous and value obvious in every other industry. In the morning, the illustrious group quickly converged around a functional definition: Value equals quality divided by cost, preferably at the clinical condition level. Fine. But then the discussion became more nuanced.

The more macro-economically inclined pointed out that the United States fails to deliver value (using our working definition) compared to peer countries. The technologists balked. We create amazing things: Mayo Clinics, proton beam facilities, medicines that cure hepatitis C. Surely there is value in that? I saw their point. While our European counterparts are well optimized to take care of the “average” patient for whom our value equation is designed, the United States is optimized to take care of the “exceptional” patient. Perhaps the Mayo Clinic doesn’t have an equivalent across the pond for a reason, and perhaps our definition of value should account for the fact that we prefer to create amazing things.

As the discussion evolved, it became clear that innovators and implementers were thinking about the value equation differently. It also became clear that, somewhere, along the arc of progress from developing an exciting new technology to deploying it at the patient’s bedside, a critical failure was happening. As a result, opportunities to generate value through innovative technology repeatedly attenuate when we try to apply them to patients. That is what we needed to get our heads around. That is what payment reform and delivery reform need to solve.

As it turns out, not everyone needs to go to the Mayo Clinic or use the latest and greatest technologies. But then again, some do. Without a well-coordinated health system, we’re unable to match our capabilities up with our needs on a patient-by-patient basis.

As we passed the microphone, there were a few rays of hope. Health and Human Services Secretary Sylvia Burwell established a timeline last month for moving the American health care payment system from volume to value; this was mentioned several times as an important catalyst for change. Also mentioned were the demonstrations of true delivery reform among a few pioneering organizations—providers who were navigating the complexity of the current system to deliver risk-appropriate, high-value care.

Emanuel put it best it in typically wry fashion: To move forward we need to “stop beating a dead fish.” Just as there are many examples of what doesn’t work, there are also shining examples of what does work. To preserve the value of promising advances in American medicine, the nation’s health care leaders need to look hard to find these positive examples, support them, and bring them to scale.


Neel Shah, MD, MPP is Executive Director of  Costs of Care, an Assistant Professor at Harvard Medical School and associate faculty at the Ariadne Labs for Health Systems Innovation.

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