As part of that concluding panel, Ezekiel J. Emanuel cautioned that no single one of the tools discussed during the entire workshop is a “magic bullet.” He described how many economists believe that proper provider incentives and payment design will fix the system; how some stakeholders speak of the panacea of health information technology (HIT); how health services researchers tout comparative effectiveness as a generator of data that will inform healthcare decision making and reshape the delivery of health care in this country; and finally, how others believe that educating consumers about the total costs of healthcare interventions and increasing cost sharing with patients will stimulate changes in behavior that will yield cost savings.

Emanuel posited that all of these elements simply constitute pieces of a toolbox that need to be engaged simultaneously and synergistically to create disruptive evolution in health care. The difficulty lies in engaging all of these tools effectively to produce incremental changes that eventually coalesce into enduring system-wide, synergistic innovations.

In this chapter’s first paper, Sir Michael Rawlins provides lessons for U.S. efforts drawn from his experiences leading the United Kingdom’s National Institute for Health and Clinical Excellence (NICE). He describes four particular challenges faced by NICE as it attempted to obtain value for patients, families, and UK society: (1) the need for direct comparative effectiveness studies between interventions, (2) the limitations in translating clinical trial results to real-world settings, (3) the difficulties in valuing treatments across clinical conditions, and (4) the incorporation of cost-effectiveness into value determinations. Although these challenges are global, he cautions that ultimately value assessments must consider the societal context, culture, and preferences of the country in which the decisions are made.

Christine K. Cassel continues with a consideration of likely future advances in medicine and a framework for understanding the value proposition in the context of these innovations, suggesting that the current environment might present a moment of disequilibrium that could catalyze reengineering of the healthcare system. Ezekiel J. Emanuel, Samuel R. Nussbaum, and John C. Rother discussed short- and long-term investment opportunities that would foster synergistic innovations and disruptive evolution toward increasing value in health care.


Sir Michael Rawlins, M.D., National Institute for Health and Clinical Excellence

The United Kingdom’s National Health Service (NHS) came into existence in 1948. Funded from general taxation, it provides care from “the

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