Editor's note: This article appears in the April 2015 issue of Global Forum. Click here to view the full publication.

Since passage of the Affordable Care Act in 2010, the last several years have seen a groundswell in physician payment and delivery reforms designed to achieve higher value health care through incentivizing higher quality care and lower overall costs. Accountable care models, for example, are achieving marked progress by realigning provider incentives toward greater risk-sharing and increased payments and shared savings with measured improvements in quality and cost containment. Medical homes are introducing greater care coordination and team-based care management, while the use of episode-based or bundled payments is removing perverse incentives that reward volume and intensity.

These reforms are coming just as the number of highly targeted, highly priced treatments continues to expand. The U.S. Food and Drug Administration (FDA) approved a decade-high 41 novel new drugs in 2014, many of them targeted therapies approved on the basis of increasingly sophisticated progress in genomics and the understanding of disease progression. In areas like oncology, such targeted treatments have grown as a percentage of global oncology market size from 11% in 2003 to 46% in 2013. New brand specialty drug spending in the U.S. is estimated to have been $7.5 billion in 2013, or 69% of total new drug spending. The growing prevalence of these drugs and their cost to the health system are setting the stage for significant flashpoints between industry, payers, and providers, seen most clearly in the debate over hepatitis C treatment costs that roiled stakeholder interactions for most of the past year. 

More of these targeted treatments are in the development pipeline, and a growing number of public policy efforts taking shape in 2015 are focused on accelerating their availability. The House of Representatives' 21st Century Cures Initiative, for example, has released a slew of legislative proposals aimed at promoting breakthrough innovation by increasing the efficiency of drug development and regulatory review. These efforts have significant downstream implications for the pace at which targeted and specialty therapies will become available, their associated costs, and the growing importance of demonstrating value in the postmarket setting.

As payers and providers continue their push toward increased value-based care, more innovative models for connecting such reforms to drug development are needed. Earlier collaboration with industry could enable more efficient identification of unmet need, opportunities to add value through drug development, and clearer input on the value proposition and evidentiary thresholds needed for coverage. Equally important will be unique public-private collaborations that invest in developing a better postmarket data infrastructure that can more effectively identify high value uses of new treatments and support achieving value through new payment reforms.

Stronger collaboration could also improve evidence development and the coverage determination process after a targeted  treatment has gained regulatory approval. Facilitated drug access programs like those proposed by the Medicare Administrative Contractor Palmetto GBA create access points for patients to receive targeted anti-cancer agents off-label while payers and industry gather important additional outcomes data in patient registries. More systematic and efficient use of policies like Medicare's Coverage with Evidence Development (CED), which allows for provisional coverage for promising technologies or treatments while evidence continues to be collected, could enable industry and payers to work together to learn about a medical product's performance in patient populations not typically represented in clinical studies. A CED-type model could be especially useful for certain specialty drugs: data collected as a condition of payment could help payers and providers develop evidence from actual practice to improve treatment algorithms, increase adherence, and improve outcomes. 

Finally, collaborations that support stronger postmarket data collection can also support novel drug payment models that further reward value. Bundled payments that include physician-administered drugs, for example, could encourage providers to increase quality while also incentivizing manufacturers to help promote evidence-based drug use and lower costs for uses that generate low value. Outcomes-based purchasing contracts that tie price paid to a medical product's performance could be another promising approach for high-expense treatment with clearly defined and feasibly measured outcomes.

Many of these ideas are not new, but as manufacturers, payers, providers, and patients move into an increasingly value-focused era of health care, it is clear that they must work together to find new ways to both promote development of promising new treatments while also making good on the promise of value-based health care reforms.

In our latest 21st Century Capitalism initiative paper, "What must corporate directors do? Maximizing shareholder value versus creating value through team production," author Margaret M. Blair explores how the share value maximization norm (or the “short-termism” malady) came to dominate, why it is wrong, and why the “team production” approach provides a better basis for governing corporations over the long term.

Blair reviews the legal and economic theories behind the share-value maximization norm, and then lays out a theory of corporate law building on the economics of team production. Blair demonstrates how the team production theory recognizes that creating wealth for society as a whole requires recognizing the importance of all of the participants in a corporate enterprise, and making sure that all share in the expanding pie so that they continue to collaborate to create wealth.

Arguing that the corporate form itself helps solve the team production problem, Blair details five features which distinguish corporations from other organizational forms:

1. Legal personality
2. Limited liability
3. Transferable shares
4. Management under a Board of Directors
5. Indefinite existence

Blair concludes that these five characteristics are all problematic from a principal-agent point of view where shareholders are principals. However, the team production theory makes sense out of these arrangements. This theory provides a rationale for the role of corporate directors consistent with the role that boards of directors historically understood themselves to play: balancing competing interests so the whole organization stays productive.

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In 2005, billionaire hedge fund manager Eddie Lampert acquired a large portion of Sears Holdings, the parent company of Sears and Kmart, among other brands. In 2008, Lampert reorganized the company into 30 autonomous business units that would operate like independent businesses, with their own IT contracts, marketing officers, and most importantly, annual financial statements. The idea was that having each unit compete for resources would drive better decision-making and boost profits overall. The exact opposite happened. The divisions turned against one another, making decisions that benefited their divisions at the expense of others. In the year after Lampert’s acquisition of Sears, the company thrived, but two years later, profits tanked, the share price plummeted, and hundreds of stores were closed. As Jillian Popadak explains in a new paper about corporate culture and firm value, erosion of corporate culture may be to blame.

It’s not the case that decentralization is always bad—some large technology companies take this approach—but in Sears’s case, the reorganization changed the norms and culture for employees, dis-incentivizing collaboration at the expense of the overall firm. Popadak notes that former Sears employees speak to this: they said the change created a “warring-tribes culture” that lacked cooperation, and “the result was confusing to the customer.” Media accounts tell a similar story. Accounts detail managers cutting floor staff to save money, intense rivalries over the space in the weekly circular, resulting in nonsense product combinations, and a paltry one percent investment in capital expenditures. Popadak argues this is an example of how important implicit norms can be when they are working to create value at the company. When the explicit emphasis on performance was introduced, it “overpowered the implicit values to collaborate, satisfy the customer, and not act selfishly.”

How can you tell if a firm’s culture creates long-term value, or even measure something so seemingly unquantifiable? Popadak argues that while corporate governance measures are designed to change the explicit rules at a company, the culture is a set of implicit rules that govern employee behavior: the expectations employees have about what it takes to be successful at the firm. In her paper, Popadak collected millions of reviews from job sites like Glassdoor.com, Payscale.com, and CareerBliss.com by year and firm, and then used the text of the reviews to create measures of firm culture based on six categories: adaptability, collaboration, customer-orientation, detail-orientation, results-orientation, and integrity. She then assessed how these measures changed when a firm underwent a governance change.

Popadak writes of this graphic, “The figure shows that firms with stronger shareholder governance exhibited statistically significant increases in results-orientation but decreases in customer-orientation, integrity, and collaboration in the year following the governance change.” In the short term, a move to results-orientation boosts sales growth and payout in the short term, but in the long term, there are “significant declines in intangible value, customer satisfaction and brand value.” Ultimately, Popadak concludes that sacrificing corporate culture for short-term payoff may not be worth it.

Policies and initiatives to promote U.S. manufacturing would be well advised to take a value chain perspective of this economic sector. Currently, our economic statistics do not include pre-production services to manufacturing such as research and development or design or post-production services such as repair and maintenance or sales. Yet, manufacturing firms invest heavily in these services because they are crucial to the success of their business. 

In a new paper, Kate Whitefoot and Walter Valdivia offer a fresh insight into the sector’s labor composition and trends by examining employment in manufacturing from a value chain perspective. While the manufacturing sector shed millions of jobs in the 2002-2010 period—a period that included the Great Recession—employment in upstream services expanded 26 percent for market analysis, 13 percent for research and development, and 23 percent for design and technical services. Average wages for these services increased over 10 percent in that period. Going forward, this pattern is likely to be repeated. Technical occupations, particularly in upstream segments are expected to have the largest increases in employment and wages.

In light of the findings, the authors offer the following recommendations: 

• Federal manufacturing policy: Expand PCAST’s Advanced Manufacturing Partnership recommendations—specifically, for developing a national system of certifications for production skills and establishing a national apprenticeship program for skilled trades in manufacturing—to include jobs outside the factory such as those in research and development, design and technical services, and market analysis.
• Higher education: Institutions of higher education should consider some adjustment to their curriculum with a long view of the coming changes to high-skill occupations, particularly with respect to problem identification and the management of uncertainty in highly automated work environments. In addition, universities and colleges should disseminate information among prospect and current students about occupations where the largest gains of employment and higher wage premiums are expected. 
• Improve national statistics: Supplement the North American Industry Classification System (NAICS) with data that permits tracking the entire value chain, including the development of a demand-based classification system. This initiative could benefit from adding survey questions to replicate the data collection of countries with a Value Added Tax—without introducing the tax, that is—allowing in this manner a more accurate estimation of the value added by each participant in a production network.

Whitefoot and Valdivia stress that any collective efforts aimed at invigorating manufacturing must seize the opportunities throughout the entire value chain including upstream and downstream services to production.

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NASA’s Asteroid Initiative encompasses efforts for the human exploration of asteroids—as well as the Asteroid Grand Challenge—to enhance asteroid detection capabilities and mitigate their threat to Earth. The human space flight portion of the initiative primarily includes the Asteroid Redirect Mission (ARM), which is a proposal to put an asteroid in orbit of the moon and send astronauts to it. The program originally contemplated two alternatives for closer study: capturing a small 10m diameter asteroid versus simply recovering a boulder from a much larger asteroid. Late in March, NASA offered an update of its plans. It has decided to retrieve a boulder from an asteroid near Earth’s orbit—candidates are the asteroids 2008 EV5, Bennu, and Itokawa—and will place the boulder on the moon’s orbit to further study it.

This mission will help NASA develop a host of technical capabilities. For instance, Solar Electric Propulsion uses solar electric power to charge atoms for spacecraft propulsion—in the absence of gravity, even a modicum of force can alter the trajectory of a body in outer space. Another related capability under development is the gravity tractor, which is based on the notion that even the modest mass of a spacecraft can exert sufficient gravitational force over an asteroid to ever so slightly change its orbit. The ARM spacecraft mass could be further increased by its ability to capture a boulder from the asteroid that is steering clear of the Earth, enabling a test of how humans might prevent asteroid threats in the future. Thus, NASA will have a second test of how to deflect near-Earth objects on a hazardous trajectory. The first test, implemented as part of the Deep Impact Mission, is a kinetic impactor; that is, crashing a spacecraft on an approaching object to change its trajectory.

The Asteroid Initiative is a partner of the agency’s Near Earth Object Observation (NEOO) program. The goal of this program is to discover and monitor space objects traveling on a trajectory that could pose the risk of hitting Earth with catastrophic effects. The program also seeks to develop mitigation strategies. The capabilities developed by ARM could also support other programs of NASA, such as the manned exploration of Mars.

NEOO has recently enjoyed an uptick of public support. It used to be funded at about $4 million in the 1990s and in 2010 was allocated a paltry $6 million. But then, a redirection of priorities—linked to the transition from the Bush to the Obama administrations—increased funding for NEOO to about $20 million in 2012 and $40 million in 2014—and NASA is seeking $50 million for 2015. It is clear that NASA officials made a compelling case for the importance of NEOO; in fact, what they are asking seems quite a modest amount if indeed asteroids pose an existential risk to life on earth. At the same time, the instrumental importance of the program and the public funds devoted to it beg the question as to whether taxpayers should have a say in the decisions NASA is making regarding how to proceed with the program.

NASA has done something remarkable to help answer this question.

Last November, NASA partnered with the ECAST network (Expert and Citizen Assessment of Science and Technology) to host a citizen forum assessing the Asteroid Initiative. ECAST is a consortium of science policy and advocacy organizations which specializes in citizen deliberations on science policy. The forum consisted of a dialogue with 100 citizens in Phoenix and Boston who learned more about the asteroid initiative and then commented on various aspects of the project.

The participants, who were selected to approximate the demographics of the U.S. population, were asked to assess mitigation strategies to protect against asteroids. They were introduced to four strategies: civil defense, gravity tractor, kinetic impactor, and nuclear blast deflection. As part of the deliberations, they were asked to consider the two aforementioned approaches to perform ARM. A consensus emerged about the boulder retrieval option primarily because citizens thought that option offered better prospects for developing planetary defense technologies.  This preference existed despite the excitement of capturing a full asteroid, which could potentially have additional economic impacts. The participants showed interest in promoting the development of mitigation capabilities at least as much as they wanted to protect traditional NASA goals such as the advancement of science and space flight technology. This is not surprising given that concerns about doomsday should reasonably take precedence over traditional research and exploration concerns.

NASA could have decided to set ARM along the path of boulder retrieval exclusively on technical merits, but having conducted a citizen forum, the agency is now able to claim that this decision is also socially robust, which is to say, is responsive to public values of consensus. In this manner, NASA has shown a promising method by which research mission federal agencies can increase their public accountability.

In the same spirit of responsible research and innovation, a recent Brookings paper I authored with David Guston—who is a co-founder of ECAST—proposes a number of other innovative ways in which the innovation enterprise can be made more responsive to public values and social expectations.

Kudos to NASA for being at the forefront of innovation in space exploration and public accountability.