The Last Mile

Analysis Complete. Execution Pending.

By the middle of 2026, the Institute of Health Economics is carrying an unusually full agenda. In the space of a year it has been named by an industry consortium as the body best placed to lead Alberta’s first outcomes-based agreement pilots¹; it has extended its public mandate from pharmaceutical evaluation into medical-imaging capacity planning at the Canada’s Drug Agency Symposium; and it has convened a major summit on the rural health workforce. Each also shares a structural feature that is easy to miss when the calendar is this full: the analysis is largely complete, and the work that remains is execution.

These are problems of a particular kind — ones where the answer is largely knowable, but where no single organization can put it into practice on its own. The right facts exist. The right intentions exist. What they wait on is a setting in which the people who control the real constraints sit together, resolve the trade-offs that have been deferred, and leave with a plan each of them owns. That is different work from the one most health-system tools are built for, and it calls for a different process.

The requirement has been described precisely from within the health-economics field itself. Alongside the technical solutions to evidence-based decision-making — reimbursement models, data standards, validation — sit the human ones, often grouped under “deliberation and consensus methods” and “the adjudication of outcomes.” That is the heart of the matter. A great deal of Alberta’s health agenda is now waiting not on better analysis but on a decision: a way to bring conflicting interests to a shared, committed resolution. This piece traces that pattern across IHE’s current agenda, then works through how a structured, decision-forcing session would play out against two of those challenges in particular.

This distinction matters in practice, and the reason is worth spelling out. A health system accumulates analysis far faster than it accumulates decisions. Reports, frameworks, and reviews are produced because they are manageable in a particular way: a capable team can be commissioned, given a question, and relied upon to return a rigorous answer. Decisions that bind multiple independent organizations do not work the same way, because no one can be commissioned to produce them — they have to be negotiated into existence by the parties themselves. The result, across most health systems, is a steadily widening distance between the quality of the analysis and the pace of the action it is meant to enable. Alberta is not unusual in this respect; if anything, the quality of IHE’s analytical output throws the distinction into relief, because the work is plainly ready to be acted upon.

A Portfolio of Solvable Challenges Awaiting a Decision

The challenges below are drawn from IHE’s own public activity over the past year. They differ in subject, but they rhyme in structure: multiple parties each hold one piece of the answer, agreement has been reached in principle, a deadline is approaching, and the strategy is poised to convert into coordinated action.

1. Outcomes-based agreement pilots that have a framework but no signed deal

IHE published a tested risk framework for outcomes-based agreements² and was explicitly identified, in the September 2025 Rare Disease Framework for Alberta¹, as well placed to lead live pilot work. The framework exists; the data capacity is said to exist; what does not yet exist is a single executed agreement with a named drug, a named payer, a named manufacturer, identified clinical sites, and enrolled patients. The reason is structural rather than analytical: payer, manufacturer, and provider each have a rational incentive to let someone else move first, and ordinary meetings produce agreement in principle without producing a signature.

2. A rare-disease funding window that closes in March 2027

Alberta secured roughly $162 million of the federal $1.5 billion rare-disease envelope. That funding sunsets in March 2027.³ At the November 2025 CORD press conference in Ottawa, IHE joined patient organizations in warning that diagnostic delays are blunting the strategy’s impact — the money exists, but patients are not reaching diagnosis and treatment quickly enough to demonstrate its value. To justify continuation, Alberta needs an agreed account of what “proven value” means and a measurement plan to demonstrate it, well before the window shuts. No single actor can define that standard alone.

What makes this a coordination problem rather than a reporting one is that “value” here is contested and distributed. The manufacturer’s account of value rests on clinical response; the payer’s rests on budget predictability; the patient organization’s rests on time-to-diagnosis and access; the federal funder’s rests on whether the bilateral investment produced something replicable. Each of these is legitimate, and none can be imposed on the others. A measurement plan that satisfies only one of them will not survive contact with a renewal negotiation. Defining the standard therefore requires the parties to agree, together and in advance, what evidence they will all accept as proof — exactly the kind of decision that tends to be postponed until the deadline removes the option.

3. Medical-imaging capacity that everyone agrees must grow

At the April 2026 CDA-AMC Symposium, IHE co-led a session on building future-ready medical-imaging capacity alongside Canada’s Drug Agency, the Canadian Association of Radiologists, and the Health Coalition of Alberta.⁴ There is broad agreement that diagnostic backlogs are urgent and capacity must expand. That agreement has not converted into coordinated procurement: capital-planning cycles, purchasing criteria, and clinical priorities are set by different bodies, and the consensus dissolves at the point where someone must commit budget against a specific plan. We return to this challenge in depth below.

4. A rural workforce that financial incentives alone will not retain

At IHE’s May 2026 Rural Health summit, the CEO of the Rural Health Professions Action Plan presented survey data from roughly 800 providers showing that signing bonuses rank lowest among retention factors, while housing, spousal employment, and team culture rank highest — and that Alberta funds only 32 rural residency seats.⁵ The levers that matter most sit outside the health ministry, in housing, education, and municipal infrastructure. No health-system body can pull them, and no standing forum convenes the ministries that can.

5. A virtual-care model that works clinically but cannot scale

Also at the summit, the medical lead of the Alberta Indigenous Virtual Care Clinic reported a 9% appointment no-show rate — well below the 20–30% often cited nationally — achieved with deliberately low-technology phone-based care. Scaling the proposed hub-and-spoke model is blocked not by clinical doubt but by a funding architecture split across federal First Nations envelopes and provincial billing codes, with no mechanism to compensate physicians for travel time. Coordination, not evidence, is the binding constraint.

6. A real-world-evidence backbone being built three times over

Outcomes-based agreements, primary-care reform monitoring, and rare-disease pathways all depend on the same real-world data infrastructure, yet each is specifying its data requirements separately — and doing so in a national AI-governance vacuum left by the lapse of federal legislation.⁶ The risk is three incompatible systems and a fresh negotiation of privacy and liability terms for every deployment. A shared architecture would serve all three, but it requires the three programs, and the privacy and data stewards, to decide together.

The cost of getting this wrong compounds quietly. Each program that specifies its own data requirements creates a parallel set of clinician workflows, governance agreements, and validation rules. Frontline clinicians, who feel the burden of every additional field they are asked to capture, are the first to disengage — and their disengagement undermines the very data on which the outcomes-based agreements and pathway-monitoring efforts depend. A shared minimum dataset, agreed once across the three programs and the privacy stewards, would lower that burden for everyone; but agreeing it requires the programs to subordinate their individual preferences to a common standard, which no program will do unilaterally and none can be ordered to do.

Read together, these are not six unrelated items on a busy organization’s to-do list. They are six instances of one pattern: constraint owners who must move together, agreement that has not hardened into commitment, and a clock. The remainder of this article is about the process that pattern actually requires.

Where the Familiar Tools Hand Off to the Next Step

Each of the familiar instruments is built for a specific job, does it well, and then hands the work onward. An evidence review sharpens the analysis, which is essential when the facts are in dispute — though here they largely are not. An advisory panel produces recommendations, which carry an agenda forward until the moment named owners and resolved trade-offs are required. A design workshop builds empathy and surfaces perspectives, invaluable early on, before the question becomes who absorbs a financial risk or which ministry funds a residency seat.

Each of these tools is good at what it is for, and the problems above have simply travelled to the stage that comes after. They are no longer short of understanding; what they now ask for is a mechanism that converts shared understanding into a binding, jointly owned decision while a deadline is still open. That mechanism has a recognizable shape, built around three deliberate stages.

The distinguishing feature of a decision-forcing process is that it treats the room itself as the instrument. Its design assumptions differ from a conference’s by intent: attendance is restricted to the people who hold the relevant authority, the agenda is built around the trade-offs that have been deferred rather than the topics that are comfortable, and the session is judged not by the quality of the discussion but by whether a committed decision exists at the end. Those constraints are demanding, which is why the format is used sparingly, only where a problem genuinely warrants it. Several of the challenges in IHE’s portfolio do.

From Evidence to Committed Action: A Three-Stage Process

The structure is simple to state and demanding to run: Analyze, then Diverge, then Converge. Its discipline lies in keeping the stages separate — surfacing the real constraints before generating options, and generating options before forcing a choice — and in insisting that the people who control the constraints are physically in the room. What follows applies the structure to two of the challenges above. The mechanics are identical; the content differs.

Worked Example A — Medical-imaging capacity and the cost of the empty slot

Analyze: Putting the Real Numbers in Front of the Real Owners

Begin with what the Analyze stage would put on the table, because in imaging the facts are unusually concrete. A missed appointment is not a neutral event; it is “false capacity” — a slot that appears productive on the schedule but yields nothing, while the staffing and overhead behind it are spent regardless. The national picture, assembled from the March 2026 CDA-AMC report and Canadian microcosting data, is large enough to command attention from a finance lead, not only a clinician.

Canada performs roughly 6.42 million CT exams a year. At the surveyed national no-show rate of about 5%, that is some 321,000 missed CT appointments, and at an audited sunk cost of $128.31 each, roughly $41 million annually from CT alone. Adding the country’s 2.2 million MRI exams at the same rate brings the CT-and-MRI floor to about $55 million.⁷ That figure is conservative: it covers only advanced cross-sectional imaging and only direct staffing cost. Extend it to the highest-volume and highest-no-show modalities and the number grows substantially. Canada performs an estimated 18.2 million X-ray exams a year at about a 4% no-show rate — some 728,000 missed appointments — which at $24 to $39 of sunk cost each adds $18 to $28 million. Diagnostic ultrasound carries the highest no-show rate of any modality at roughly 7%, generating about 700,000 missed appointments against an estimated 10 million exams, adding some $40 million at $57 to $61 per missed appointment.⁸ The national averages also conceal sharp local variation — ultrasound no-show rates exceed 25% in some jurisdictions — which means the burden is concentrated, and therefore addressable, in specific sites.

The point of the Analyze stage is not to admire these numbers but to use them to surface what each actor in the room actually controls. The figures make plain that no single party owns the problem. A regional imaging director controls scheduling and reminder protocols but not capital. A provincial capital-planning office controls equipment budgets but not the clinical criteria that decide which backlog is most urgent. Canada’s Drug Agency controls the assessment methodology but not procurement. Radiologists control read capacity but not patient access. The Analyze stage invites each of these to state, in front of the others, the constraint they own and the one they do not — a conversation that the conference format, for all it accomplishes, more often leaves to the corridor than to the agenda.

Diverge: Generating Options That Cross the Boundaries

The Diverge stage then generates options that a single panel, left to itself, would not reach — because the options that matter cut across the boundaries the actors arrived with. A reminder-and-overbooking protocol tuned to the highest-no-show modalities is one lever; a shared capital-prioritization rule that ranks investment by recovered effective capacity rather than by headline machine count is another; a vendor-neutral procurement standard that lets provinces buy against common criteria is a third. The value of separating this stage is that it suspends, briefly, the instinct to defend existing budgets long enough for combinations to appear.

Crucially, the Diverge stage is bounded by the constraints established in the Analyze stage, which keeps it from drifting into wishful options no one in the room can deliver. An idea survives only if some party present can own it. This is the quiet discipline that separates a structured divergence from a brainstorm: the goal is not the longest list of possibilities but the set of genuinely actionable combinations that no participant would have proposed alone, because each sits across a boundary that only the assembled group can cross together.

Converge: Decisions Built to Survive the Return Trip

The Converge stage is where the process earns its keep. It produces not a recommendation but a decision: a 30/60/90-day plan in which a named capital office commits to a prioritization rule, a named regional director commits to a no-show protocol at identified high-variance sites, and a named methodology lead at the assessment body commits to the criteria those decisions will be measured against. The deliverable is a record of who will do what, by when, with the trade-offs already resolved in the room rather than carried forward to a future session.

The imaging data lends itself naturally to this discipline. Because the sunk cost of a missed appointment is concrete and auditable, and because the no-show burden concentrates in identifiable high-variance sites, the Converge stage can attach each commitment to a measurable baseline. The capital office’s prioritization rule can be tested against recovered effective capacity; the regional director’s protocol can be measured against the specific no-show rate at the sites it targets. A decision that can be measured is a decision that can be defended — which matters greatly to an audience of evaluators and methodologists, and is one reason the imaging challenge is a particularly clean demonstration of the method.

Worked Example B — The rural workforce and the levers no one ministry holds

Analyze: Naming the Levers and Who Actually Holds Them

The same structure applied to rural workforce retention exposes a different shape of constraint, and this is where it is most useful. The Analyze stage starts from the summit’s own finding: financial incentives, the lever the health system most readily controls, are the least effective at retention, while the most effective levers — housing, spousal employment, schooling, broadband, and the size of the residency pipeline — sit with municipalities, the education ministry, and infrastructure planning. Stating this plainly in a shared room reframes the problem from “a staffing shortage health must fix” to “a cross-ministry investment decision,” which is the only framing under which it can actually be resolved.

As with imaging, the point of the Analyze stage is to make visible that each lever is owned by a different actor and none moves the others. Set out as a set of interlocking dimensions, the structure of the problem becomes legible — and so does the reason it has stayed open:

Diverge: Building Options Across Jurisdictional Lines

The Diverge stage then generates options that no single ministry would propose on its own, because each crosses a jurisdictional line: an ROI model that translates the cost of a rural emergency-department closure into a shared business case across health, infrastructure, and advanced education; a “grow-your-own” residency expansion past the current 32 seats tied to community-integration supports; and a hub-and-spoke delivery model — borrowed directly from the Indigenous virtual-care challenge — with the travel-time billing mechanism that currently blocks it built in from the start.

The same boundedness applies here, and it is what makes the rural case workable rather than utopian. It would be easy, in an unstructured session, to conclude that rural retention requires solving rural housing — a true statement that helps no one, because no party in the room can solve rural housing. The Analyze stage prevents this by establishing precisely what each participant can commit: a residency-seat number, a connectivity pilot in one community, a billing-code change. Divergence then works within those commitments, assembling them into a package whose pieces are individually deliverable and collectively greater than what any ministry would have offered on its own.

Converge: Sequencing Commitments So None Is Left Stranded

The Converge stage forces the commitment that summits, by design, are not built to extract: advanced education names a residency-seat number and a date; the infrastructure or municipal-affairs representative commits to a housing or connectivity pilot in a specific community; health commits to the billing-code change that compensates travel. Because the trade-offs — who funds what, in what order — are resolved in the room with the relevant authorities present, the plan that leaves the room is one each signatory has already agreed to own.

The sequencing of those commitments is itself part of the decision. Because the levers are interdependent — a residency graduate will not stay without housing, and a hub-and-spoke physician cannot be deployed without a travel-time code — the Converge stage must resolve not only who acts but in what order, so that no commitment is left stranded waiting on another that was never made. The 30/60/90 structure exists for exactly this: it stages the interdependent moves into a sequence each party can see and agree to, which is what allows a plan involving three ministries to hold together once everyone has left the room.

Convening, and the Process That Sits Naturally Beside It

Organizations like IHE — and Canada’s Drug Agency, and their peers — convene constantly, and they do it well. In the past year alone the calendar has included an Alberta health-economics seminar, a monthly health-economics rounds series, a national press conference, a discrete-choice-experiments training course, a Rare Disease Day webinar, an international HTA webinar, the CDA-AMC Symposium, and a hybrid rural-health summit. These gatherings do real work: they bring the right people into contact, surface the evidence, and build the relationships that later action depends on. The question is not whether they are valuable — they plainly are — but what each format is shaped to produce, and what naturally falls to a different one.

A conference is built for a particular kind of work, and the same is true in every health system. A symposium is, at its core, a sequence of presentations and discussions, and at its best it confirms where stakeholders already agree, deepens shared understanding of the underlying causes, and surfaces which solutions are worth exploring. What the form does not do — anywhere — is force trade-offs between competing options or test those options against the people who would have to implement them. Those people are rarely at the table; senior leaders attend in their place, and agreement reached at that altitude tends to stay general. Options get described rather than pressure-tested, and the session closes before anyone has had to choose between them. None of this is a failing of the organizer. It is the boundary of the format, and knowing where that boundary sits is what signals when a second kind of session is due.

There is a clear test for when that moment has arrived. Look across several years of the calendar and ask one question: are the same issues being explored, in much the same terms, year after year? Where complex challenges are steadily being resolved and moved off the list, the existing tools are doing their job and there is no reason to reach for another. Where a few hard problems keep returning to successive agendas, that recurrence is itself the signal — usually that the challenge has travelled past the point where more discussion adds much, into territory where progress depends on a different kind of process: one built to bring the implementers into the room, test real options against real constraints, and force a committed decision. The choice, then, is not between convening and something that replaces it. It is whether to set, alongside the convening IHE already does so well, the occasional session whose purpose is to convert alignment into committed action while a deadline is still open. The two are complements: a symposium can establish that imaging capacity must grow and that the evidence supports it; a structured, time-boxed deliberation is what turns that shared conclusion into a capital-prioritization rule with a named owner and a date. With the rare-disease funding window closing in March 2027, the value of the second kind of session is at its highest precisely now.

The Question Before the Window Closes

Each of the challenges in IHE’s portfolio is, in the most important sense, solvable. The evidence is in hand or within reach; the intentions are aligned; the people who would need to act are, for the most part, willing. What remains is the setting that brings willing parties to a shared decision before the moment passes. The analysis has done its job. The remaining question is narrower and more immediate than another study can answer: in the time still available, will the alignment IHE has so capably built be converted into a plan that named people have committed to own — turning, as the best work in health systems eventually must, an excellent conversation into a decision.