The Affordable Care Act’s emphasis on patient centered outcomes requires a re investigation of the assumptions underlying efficiency and effectiveness of the healthcare system as a whole. At the core lies an understanding of what constitutes value, and is the value provided by healthcare delivery systems the same as the value of “health”. A number of questions need to be asked: What does the patient consider to be a valuable outcome? Can patients really make such a determination? In a multi-stakeholder system such as healthcare, is the understanding of “value” the same across all stakeholders? Are all stakeholders capable of understanding what is of value to patients? Do they have the knowledge and information to make that determination? Do we need to have an agreement on what constitutes “value” in a patient centered system? If yes, how will such an agreement come about? If not, what incentives are required in different parts of the system to have a common outcome in the most efficient way? Will increasing value also increase cost? On whom will most of the cost burden fall? If overall value increases but cost to some stakeholders increase how will change be successfully implemented? And the overarching concern, will a system that delivers higher value to patients be sustainable? What incentive mechanisms are necessary to coordinate the “business model” with the “clinical model” in improving health?

These and other questions require much research and dialog amongst different stakeholders: patients, providers, payers, and the industry. Such a dialog has to identify the issues related to value that would help us create policies and develop metrics which would efficiently determine whether interventions and innovations have been appropriately designed and have the desired effect on patient outcomes and overall health.   At the operational level we need to develop appropriate short term and long term indicators of “impact” of changes willfully introduced and occurring in an unanticipated way as the system transforms itself through new policy mandates, new business opportunities and new developments in science and technology.