Ross and Fenster are right: ultimately, we should be managing value because it is the right thing to do. In addition, it may well promote marketshare, cut costs, and provide a framework for making some of the difficult decisions that will confront health care in the coming years. The authors are also correct that all too few health care leaders are focusing today on the value-based approach to medical care delivery and that the numbers will increase in time because, as I see it, managing value must be one of the cornerstones for the reengineering revolution that is occurring in health care today. For me, one of the most difficult elements in a very thought-provoking article was dealing with the complexities of the definition of managing value. Noting that it is an elusive term that raises the specter of chaos, Ross and Fenster propose a working equation involving appropriateness of care, quality of outcomes and service, and cost. While one can hope that purchasers and providers will come to recognize that the value of health care services provided is critical, there is a need for new strategies that transform organizational and clinical priorities and practices. Ross and Fenster point out that the need to subscribe to the management of value becomes more important as the contest intensifies between society's infinite demand for health care services and the finite resources available. Ross and Fenster describe the critical role of the executive and management team in moving toward a health care system based on value; explain the need for a long-term commitment from the board of trustees, physicians, and in fact, the entire organization; and discuss in considerable and striking detail the many pitfalls and hazards awaiting anyone embarking on this journey. The article makes many valuable contributions to the body of literature on change sweeping health care today, including identification of several steps leaders must consider as they launch an effort to create a value-based approach to medical care delivery, pointing out that there are no quick fixes, and providing a very useful list of references. Organizational Transformation Requires is a Multidimensional Strategy The central problem for every health care executive today is to determine the vision, mission, leadership plan, and strategic initiatives and to implement actions for transforming their health care organization so it can be relevant for the future. As an executive who is attempting to organization and who works transform his own with health care organizations throughout Pennsylvania, I have spent considerable time analyzing the forces creating health care reform and looking for ways in which leaders successfully respond when these forces hit their service area. Pennsylvania health care executives are faced with a period of unprecedented change. The strategic assumptions that guide their actions include the following: * Health care will be driven by community and market forces, with government intervention largely limited to minimal, incremental initiatives aimed at addressing discrete episodes of market failure. * Market forces are far less predictable and far less forgiving than government mandates. They thus require unprecedented speed and flexibility from providers in responding. The ability to provide quality care at a reasonable price and simultaneously to improve the health status of one's community (i.e., the risk pool) will be the critical success factor for the health care delivery systems of the future. * Capitated financing will dominate the Pennsylvania health care market within the next three years, led by Medicare, Medicaid, and employed groups. This is making Pennsylvania attractive to out-of-state for-profit HMOs. * The ability to directly assume risks is important to providers. At present, few hospitals are positioned to quickly and successfully assume full capitation risk for large numbers of covered lives. …