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U.S. health care costs currently exceed 17% of GDP and continue to rise. One fundamental reason that providers are unable to reverse the trend is that they don't understand what it costs to deliver patient care or how those costs compare with outcomes. To put it bluntly, few health care providers measure the actual costs for treating a given patient with a given medical condition over a full cycle of care, or compare the costs they incur with the outcomes they achieve. What isn't measured cannot be managed or improved, and this is all too true in health care, where poor costing systems mean that effective and efficient providers go unrewarded, and inefficient ones have little incentive to improve. But all this can be remedied by exploring the concept of value in health care and carefully measuring costs. This article describes a new way to analyze costs that uses patients and their conditions-not organizational units or narrow diagnostic treatment groups-as the fundamental unit of analysis for measuring costs and outcomes. The new approach, called time-driven activity-based costing, is currently being implemented in pilots at the Head and Neck Center at MD Anderson Cancer Center in Houston, the Cleft Lip and Palate Program at Children's Hospital in Boston, and units performing knee replacements at Schon Klinik in Germany and Brigham & Women's Hospital in Boston. As providers and payors better understand costs, they will be positioned to achieve a true "bending of the cost curve" from within the system, not in response to top-down mandates. Accurate costing also unlocks a whole cascade of opportunities, such as process improvement, better organization of care, and new reimbursement approaches that will accelerate the pace of innovation and value creation.

Describes the Dutch Flower cluster, or the group of interconnected growers, suppliers, service providers, and flower-related institutions located in The Netherlands. Examines the role of the FloraHolland auction in the value chain. Also describes the flower clusters in China, Colombia, Ecuador, and Kenya, the four other major international competitors.

HBR asked top management thinkers to share what they were resolved to accomplish in 2011. Here are their answers: Joseph E. Stiglitz will be crafting a new postcrisis paradigm for macroeconomics whereby rational individuals interact with imperfect and asymmetric information. Herminia Ibarra will be looking for hard evidence of how "soft" leadership creates value. Eric Schmidt will be planning to scale mobile technology by developing fast networks and providing low-cost smartphones in the poorest parts of the world. Michael Porter will be using modern cost accounting to uncover-and lower-the real costs of health care. Vijay Govindarajan will be trying to prototype a $300 house to replace the world's poorest slums, provide healthy living, and foster education. Dan Ariely will be investigating consumers' distaste for genetically modified salmon, synthetic pharmaceuticals, and other products that aren't "natural." Laura D. Tyson will be promoting the establishment of a national infrastructure investment bank. Esther Duflo will be striving to increase full immunization in poor areas of India. Clay Shirky will be studying how to design internet platforms that foster civility. Klaus Schwab will be undertaking to create a Risk Response Network through which decision makers around the world can pool knowledge about the risks they face. Jack Ma will be working to instill a strong set of values in his 19,000 young employees and to help clean up China's environment. Thomas H. Davenport will be researching big judgment calls that turned out well and how organizations arrived at them. A.G. Lafley will be proselytizing to make company boards take leadership succession seriously. Eleven additional contributors to the Agenda, along with special audio and video features, can be found at hbr.org/2011-agenda.

The capitalist system is under siege. Recently business has been criticized as a major cause of social, environmental, and economic problems. Companies are widely thought to be prospering at the expense of their communities. Trust in business has fallen, leading governments to set policies that undermine competitiveness and sap economic growth. Business is caught in a vicious circle. A big part of the problem is firms' narrow approach to value creation. Focused on short-term financials, companies overlook the broader influences on their long-term success. Why else would they ignore the well-being of their customers, the depletion of vital natural resources, the viability of suppliers, and the economic distress of the communities in which they produce and sell? It doesn't have to be this way. Companies could bring business and society back together if they redefined their purpose as creating "shared value"-generating economic value in a way that also produces value for society by addressing its challenges. Firms can do this in 3 ways: by reconceiving products and markets, redefining productivity in the value chain, and building supportive industry clusters near their locations. A number of leading firms have already embarked on such initiatives. Nestle, for example, redesigned its coffee procurement, providing small, impoverished farmers advice on agricultural practices; helping them secure plant stock, fertilizers, and pesticides; and paying them a premium for better beans. Higher yields and quality increased the growers' incomes, the environmental impact of farms shrank, and Nestle's reliable supply of good coffee grew significantly. Shared value was created. Shared value could transform capitalism. It could also drive the next wave of innovation and growth as it opens managers' eyes to immense human needs to be met, large new markets to be served, and the internal costs of social deficits-as well as the competitive advantages available from addressing them.

In 2010, organ transplantation remained among the few sets of medical conditions in the US for which bundled payments were a dominant reimbursement model, and for which patient health outcomes were universally measured and reported. In 1986, UCLA Medical Center was approached by Kaiser to develop a new bundled pricing approach to kidney transplant care that was quickly adopted by many payers and providers for various transplant types. This case study examines the history and current state of care delivery, reimbursement, and measurement for the UCLA Kidney Transplant Program, among the nation's highest-volume transplant providers. The UCLA Kidney Program is an interdisciplinary unit that involves clinicians from multiple Departments and engages in continuous care management throughout the often protracted transplant care cycle.

Looking through the lenses of both macro and micro economic policy, this case examines how Singapore has achieved such stellar success throughout its history, from independence through 2008. The case discusses the different policy choices the Singaporean government has made as well as how the government's structure has aided development.

Sweden's Highland District County Hospital, similar to a community hospital in the US, undertook a major restructuring to integrate care delivery for medical conditions served by the Department of Medicine. Each subspecialty within the Department would form a single, co-located unit with its own budget that encompassed both inpatient and outpatient care. This case examines the experience of the Highland Gastroenterology Unit, comparing the delivery model for inflammatory bowel disease in 2001 and 2009, before and after the reorganization. The case can be used to examine health care provider strategy, integrated care delivery, and quality measurement. The case also profiles Sweden's single-payer health care system, allowing for a discussion of national health systems and health policy.

Ledina Lushko was diagnosed with Adrenal Cortical Carcinoma in 2008 and sought care at a highly regarded medical institution in the United States. This case lays out her journey through the health care system in detail and all of the effort involved in finding appropriate care. It is meant not to illustrate good or bad care, but to reflect on the nature of the current health care delivery system and serve as a starting point for discussion.

Taiwan's Koo Foundation Sun Yat-Sen Cancer Center has developed an integrated, team-based care delivery model for breast cancer care that is being expanded to other cancer types in 2009. A decade earlier, President and CEO Dr. Andrew Huang and the Center had worked with the Taiwan National Health Insurance system to create a pay-for-performance reimbursement program for breast cancer care that has since been adopted by five other providers. The program issues capitated, per patient base payments for breast cancer care, with bonus payments based upon provider reporting and performance on a set of quality measures. This case allows readers to examine health care provider strategy, development and implementation of bundled reimbursement, integrated care delivery, quality measurement, and Taiwan's universal health care system.

The Joslin Diabetes Center in Boston, Massachusetts is a leading center for diabetes care, clinician training, and research. The incidence of diabetes is rising precipitously worldwide, challenging quality of life with its complications and rapidly accelerating health care expenditures for employers and governments. The Joslin's multispecialty, team-based care and patient education programs provide opportunities to examine integrated practice units, early-stage and preventive care, and clinical coordination along the full care cycle. The focus on diabetes also enables discussion of what services need to be included in integrated practice units serving patients with complex, chronic diseases. However, despite its renown, the Joslin's clinical operations lose money, raising the challenge of how to align financial success and clinical success in health care delivery. The case can be used to teach strategy in health care delivery, value creation, outcome measurement, reimbursement, and strategic alliances.

The case is designed to explore the process of building competitiveness, particularly in an unstable environment, with a focus on organizations for competitiveness.

Global Health Partner was founded in 2006 as a privately owned health care provider in Sweden serving both public and private paying patients. In contrast to most providers in the country, GHP organized around specific service lines where it saw the potential to provide the most value. This case details the GHP approach to both Spine Care and Obesity Care demonstrating the power of specialization for quality improvement as a basis for competitive advantage. Students will examine the organization of integrated multidisciplinary care, the impact of volume on learning and efficiency , and the importance of demonstrating quality through outcomes reporting. The case also provides a window into the Swedish Health Care System.

In 2005, Partners In Health (PIH) was invited by the Rwandan Ministry of Health to assume responsibility for the management of public health care in two rural districts in Eastern Rwanda and create an HIV treatment program at these sites. PIH successfully implemented a comprehensive program focusing on 4 principles: health systems improvement, HIV prevention and care, accompaniment, and social and economic support. By January 2007, the Rwinkwavu site had conducted 67,137 HIV tests and provided antiretroviral therapy to more than 2,000 patients, of which, fewer than 1% had been switched to second-line drug regimens, 3.8% had died and only one patient had been lost to follow up. A costing analysis done by the Clinton HIV/AIDS Initiative suggested that the model could feasibly be spread to other districts. Dr. Agnes Binagwaho, Executive Director of Rwanda's National AIDS Control Commission and her colleagues in the Ministry of Health are contemplating how the program could be improved and whether it should be expanded nationally.

Describes the Spine Center at Dartmouth-Hitchcock Medical Center, a multidisciplinary unit that offers patients suffering from spinal problems "one-stop" access to a range of providers including orthopedic surgeons, neurosurgeons, neurologists, medical specialists in physical medicine and pain management, mental health providers, and occupational and physical therapists. The Center was created to address what its founder, James Weinstein, M.D., saw as the uncoordinated and inefficient delivery of spinal care in the United States. The Center emphasized using non-surgical treatments (e.g., physical therapy and exercise, behavioral modification, pain-relieving drugs) as either a complement to, or substitute for, surgical procedures, and patients were actively engaged in the process of determining what type of care to pursue. In addition, Weinstein and his staff collected data from the Center's clinical practice to conduct academic research on the outcomes and cost-effectiveness of various approaches to treatment. The case allows for a critical analysis of the Spine Center's unique approach to care delivery and provides an opportunity to examine the applicability of this model in other clinical areas.

The Cleveland Clinic's health care services are internationally renowned for quality. In 2008, The Clinic began to restructure the organization into teams defined around patient needs, rather than traditional medical specialties."Patients First! takes shape as the teams measure and report outcomes, coordinate care, and develop to support improving value for patients. In addition to restructuring care delivery in the hospitals and throughout northeastern Ohio, The Clinic has investments, facilities, and staff in several other states in the U.S. as well as in Canada and Abu Dhabi. Now in 2015, as the Clinic's domestic and international footprint continues to expand, its leadership is also focused in maintaining the Cleveland Clinic brand and providing optimal clinical care. Students can explore strategy transformation, geographic expansion, the process of introducing new measurement approaches, alignment of activities with strategic goals, and issues in leading change both within a company and across an economic sector.

Pitney Bowes, a Fortune 500 mail and document management firm, offered its first health plans in the years following World War II. Over the ensuing decades, Pitney Bowes adapted its approach to employee health amid rising health care costs, shifting employer attitudes towards health benefits, and a rapidly changing policy environment. By 2008, the firm was widely regarded as an innovator in employee health, having dedicated substantial time and resources to its health benefits under the leadership of then CEO Michael Critelli and Corporate Medical Director Jack Mahoney. The case provides an overview of the history of employee health benefits in the U.S. and at Pitney Bowes. The range of health plans Pitney Bowes offered to employees in 2008, as well as the firm's contracting policies with commercial insurers and self-insured plan administrators, are examined in detail. Pitney Bowes health and wellness programs are also described, enabling an analysis of the firm's overall employee health strategy in 2008 and a discussion of where Pitney Bowes should focus its attention moving forward.

As of 2007, there were very few examples of widespread measurement and reporting of health outcomes, a critical quality measure. In-vitro fertilization clinics have been required to report their patient's health outcomes since 1995. The protagonist of the case, Dr. James Goldfarb, faces a number of challenges. As the medical director of a nationally-renowned fertility program at the Cleveland Clinic, he must run an efficient and effective practice that draws patients from both the surrounding area and from around the world. As a leader of the Society for Assisted Reproductive Technology, he must contribute toward the continuing evolution of the practice of in-vitro fertilization and ensure that the outcome measurement system is creating proper incentives and delivering timely, accurate, and useful information to patients, physicians, and researchers.

Considers the situation facing Gary Gottlieb, president of Brigham and Women's Hospital (BWH), prior to the opening of BWH's integrated cardiovascular center. This case allows students to develop an appreciation of the strategic, financial, organizational, clinical, and physical aspects of integrating health care delivery around specific categories of disease. It provides an opportunity to evaluate BWH's approach to integration along all of these dimensions and to identify the nature of the tradeoffs that hospitals--specifically, academic medical centers--face as they attempt to create disease-specific models of integrated care. Finally, students have the opportunity to evaluate the degree to which integrated models of care can be developed within academic medical centers.

In 2006, University of Texas MD Anderson Cancer Center was an internationally leading institution for cancer care, education, and research. Since 1996, it had successfully reorganized itself from a cancer hospital that was physically organized around clinical specialties into one that was organized into disease-based integrated practice units called multidisciplinary care centers. These units were supported by a new construction project that had created new disease-specific facilities and a widely-supported administrative plan in which physicians reported both to leadership of specialty-based academic departments and disease-based clinical centers.

Individuals enrolled in both Medicare and Medicaid, known as dual eligibles, are among the highest-cost beneficiaries in the US. Commonwealth Care Alliance, a small nonprofit insurer and care delivery system in Massachusetts, operated under a public demonstration program designed to provide comprehensive coverage and care for the elderly dual eligible population. Led by Dr. Robert Master, Commonwealth Care Alliance worked with its contracted providers to implement and support a care delivery model that could allow as many members as possible to live independently outside of nursing homes. The case examines Commonwealth Care Alliance's insurance and care delivery approaches amidst a changing policy environment and various resource constraints. This case can be used to teach: Approaches to value-based insurance and care delivery; Insurance and care delivery considerations for underserved, high-cost populations; Evolution and structure of US Medicare and state Medicaid programs and demonstrations; and payer and provider reimbursement models.