From Expected Value to Realized Value: An Agenda for Healthcare Transformation

Kelly Saldaña, Executive Director, ISPOR Institute for Healthcare Transformation

Health economics and outcomes research (HEOR) has given healthcare decision makers a disciplined way to assess value. Applying HEOR methods helps estimate outcomes and costs, make trade-offs visible, characterize uncertainty, and clarify the opportunity costs of choosing one use of scarce resources over another. Healthcare transformation happens when the value identified through HEOR can be converted into sustained patient benefit without unrecognized losses elsewhere in the system. That’s why the ISPOR Institute for Healthcare Transformation was created: to strengthen the path from evidence and decisions to real-world application and patient benefit.

As a new organization within ISPOR with a mandate for healthcare transformation, the ISPOR Institute can help connect HEOR’s comparative rigor with other fields that focus on the conditions under which assessed value is actually achieved, translating those insights for the practitioners and decision makers responsible for implementation. The concept of “realized value” offers a way to ask, with scientific discipline, what happens after an assessed (or claimed) value proposition encounters real financing arrangements, delivery systems, implementation processes, and patient lives. It also offers a way to identify practical actions that can strengthen the pathway to impact.

Realized value offers a way to ask what happens after an assessed value proposition encounters real financing arrangements, delivery systems, implementation processes, and patient lives.

The Institute proposes using realized value as the next step in an ongoing evolution of HEOR and health technology assessment (HTA), reflected in the related concepts of life cycle HTA and living HTA. Life cycle HTA extends assessment beyond initial adoption to evidence development, monitoring, reassessment, optimization, and potential disinvestment as evidence, technologies, or context change. Living HTA emphasizes a responsive, up-to-date assessment process as new evidence emerges, drawing on methods such as continual evidence surveillance, iterative review, and potentially digital tools.

Together, these concepts represent important advances because they recognize that value propositions evolve over time. Realized value builds on that evolution by shifting the main unit of inquiry from the assessment process itself to the applied settings where decisions are financed, implemented, adapted, experienced, and sustained.

This framing emerged from what Institute leaders heard and synthesized at a one-day convening in Boston in August 2026. For the event, the Institute brought together researchers, decision makers, and implementers working across HEOR, HTA, health systems strengthening, implementation science, policy, academia, and industry. Across those perspectives, participants converged on a shared challenge: healthcare transformation requires more than better evidence or better decisions at a single point in time. It requires disciplined ways to follow value as its context progresses from evidence to policy, practice, and patient experience, and to identify where that value is enhanced, preserved, diluted, or lost along the way.

In the context of HEOR, moving from inquiry to application is central to the ambition of healthcare transformation. The realized-value frame draws on:

• HEOR to specify expected value

• implementation and health policy research to examine adoption and execution

• health-systems analysis to locate organizational and financing constraints

• political economy to examine authority, interests, incentives, and feasibility from the outset

• equity-informed economic evaluation to identify where inequities and inefficiencies intersect (particularly where access, diagnosis, or delivery barriers affect who benefits and how much value is realized)

These analytic disciplines are paired with applied disciplines that translate diagnosis into action: HTA, health systems strengthening, implementation practice, and thinking and working politically bring those insights into ongoing decisions and action.

Realized value gives all of these perspectives a common organizing frame: specify expected value, identify where it breaks down, understand why it breaks down, and translate that diagnosis into applied practice that supports implementation, adaptation, and learning in real systems. Gaps between expected value and realized value may reflect inaccurate assumptions, changing context, implementation constraints, or shifting objectives; distinguishing among them matters because each requires a different remedy.

Methodologically, this calls for a comparative, empirical, and mixed-methods approach that uses quantitative measures of outcomes, costs, access, equity, and implementation alongside qualitative evidence on mechanisms, context, stakeholder experience, authority, incentives, and political feasibility, understanding the limitations of making specific causal claims in complex settings.

Illustrative Example

A medicine demonstrates favorable expected value at the time of assessment, but diagnostic delays, restrictive coverage rules, high out-of-pocket costs, fragmented referral pathways, or limited provider capacity prevent the medicine’s timely and sustained use by patients. A realized-value inquiry would examine where along that pathway expected benefit is preserved, diluted, or lost, and explore how policy, financing, delivery, or implementation changes could potentially close the gap.

The reason to trace these pathways is practical. Without understanding where and why value is preserved, diluted, or lost, decision makers can mistake an implementation failure for a failure of the therapy itself, overlook avoidable losses of access or benefit, or miss opportunities to improve impact through financing, delivery, accountability, or patient-facing changes.

To make realized value operational, a product, service, or intervention can be traced in 2 directions. A patient-backward pathway begins with a consequential moment in the care journey: delayed diagnosis, treatment abandonment, an avoidable complication, financial distress, or a transition that worked well, and examines how specific features of that journey shaped access to, use of, experience with, or benefit from the product, service, or intervention. It then traces backward to the policy, financing, organizational, implementation, and accountability conditions that helped produce that consequential experience. Existing research offers methods for doing this carefully, including patient journey mapping, patient-reported experience analysis, and case-study approaches that can identify barriers, facilitators, mechanisms, and competing explanations without assuming simple causality.

A policy-forward pathway begins with a specific policy or system decision affecting a product, service, or intervention (such as coverage, reimbursement, procurement, guideline adoption, benefit design, or service redesign) and examines how access, use, experience, or benefit changes such as financing arrangements, institutional responsibilities, delivery processes, implementation choices, and patient-facing conditions respond. Implementation outcomes—including acceptability, adoption, feasibility, fidelity, appropriateness, implementation cost, penetration, and sustainability—can be distinguished from service and patient outcomes to identify where expected value is realized, diluted, or lost.

Across both pathways, political economy provides foundational understanding and contextualization from the beginning. It helps define what is being studied, why particular bottlenecks or successes arise, how authority, interests, incentives, and institutions shape the pathway from evidence to impact, and what kinds of action are feasible in a given setting. This understanding then informs case selection, pathway mapping, stakeholder engagement, and feasibility assessment. Tracing value backward from patient experience or forward from policy decisions can identify where value is lost, while political-economy analysis helps explain why breakdowns or successes occur and where coalitions for change might emerge.

Within this realized value frame, the Institute will work to distill the complex path from evidence to policy to practice through a clear approach for moving from inquiry to application. The Institute has a Definition–Consensus–Implementation approach:

• It begins by clarifying the problem, the value expected, the pathway through which that value should reach patients and systems, and the evidence, system, or political-economy questions that need to be addressed.

• It then brings affected stakeholders into structured deliberation to distinguish symptoms from root causes, weigh values and evidence, and identify feasible actions with clear owners.

• Finally, it supports bounded implementation in real settings, with measurement, adaptation, and learning including, where needed, thinking and working politically as an applied approach for navigating authority, incentives, coalitions, and changing context.

Using this approach, the Institute can build a realized value portfolio: a practical body of tracer cases, tested actions, and comparative lessons that help healthcare transformation move from evidence to impact.

ISPOR has helped healthcare identify and assess value with rigor. The Institute now has an opportunity to help the community follow that value through real systems: from evidence to decisions, from decisions to institutions and delivery, and from delivery to the outcomes and experiences that matter to patients.

To the ISPOR community, the Institute extends an invitation that is ambitious and practical: apply the profession’s rigor not only to estimating value, but also to understanding whether and how that value becomes real.