Debates over value in health innovation in the U.S. and Europe have become increasingly dominated by "value-based pricing". We examine this prevailing narrative and its weaknesses and then present an alternative framework for rethinking value in health. Drawing on scholarship from the political economy of innovation, we argue that value in health must be considered in terms of both value creation as a collective process amongst public and private actors, as well as value extraction that occurs due to financialization. In building this alternative framework, we pose three questions that present areas for further research and public policy change. KEYWORDS Value-based pricing; public value; health economics JEL CLASSIFICATIONS I18; H40; L16; O3 Policy Highlights • Prices of drugs should be better aligned to the actual risk sharing between public and private actors, rather than myths around value created by a narrow set of actors. • Policy can be used to steer public purpose missions in healthnot only to de-risk private costs. • Markets are outcomes of public and private investments, hence health innovation policy should be seen not as "regulating" or intervening but as actively co-shaping markets.

Victor Roy and Lawrence King argue that the acquisition strategies of drug companies magnify development costs and leave the public paying twice—for research and high priced medicines

Capitalizing a Cure takes readers into the struggle over a medical breakthrough to investigate the power of finance over business, biomedicine, and public health. When curative treatments for hepatitis C launched in 2013, sticker shock over their prices intensified the global debate over access to new medicines. Weaving historical research with insights from political economy and science and technology studies, Victor Roy demystifies an oft-missed dynamic in this debate: the reach of financialized capitalism into how medicines are made, priced, and valued. Roy’s account moves between public and private labs, Wall Street and corporate board rooms, and public health meetings and health centers to trace the ways in which curative medicines became financial assets dominated by strategies of speculation and extraction at the expense of access and care. Provocative and sobering, this book illuminates the harmful impact of allowing financial markets to determine who heals and who suffers and points to the necessary work of building more equitable futures.

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Within the FIGHT study population, Carbone and colleagues inquire about how quantitative differences in LVEF affected responses to liraglutide within the larger population of patients with advanced heart failure and reduced LVEF. In the requested subgroup analysis (Table ), liraglutide treatment was associated with signals of worse outcomes among patients with an LVEF above the median (25%), but responses were not significantly different from placebo among those with an LVEF at or below the median. Owing to the entry criteria of the FIGHT trial, even the group with LVEF above the median had severely reduced systolic function and other factors indicating increased risk. Nevertheless, a greater severity of LVEF reduction does not appear to be driving adverse effects of liraglutide within a population composed of patients with advanced heart failure.Carbone and colleagues also consider the possible effect of body composition on responses to GLP-1 agonists and inquire whether patients' BMI or weight loss during the trial affected their responses to liraglutide. Specifically, there is concern that further weight loss among already cachectic patients may have contributed to adverse outcomes. In this context, it is important to highlight that in the FIGHT cohort, the median (interquartile range) BMI was 32 (26-37). The requested subgroup analysis (Table ) indicates that liraglutide treatment was not associated with worse outcomes among patients with BMI at or above or below the median. Unlike baseline BMI, the magnitude of weight loss cannot be predicted at onset of treatment and thus cannot influence the decision to prescribe liraglutide in patients with advanced heart failure.Overall, it appears that the safety concerns about liraglutide among patients with advanced heart failure arise specifically regarding patients with type 2 diabetes. These findings underscore our suggestion for caution when initiating liraglutide for the sake of diabetes management among patients with advanced heart failure.