**9. Conclusions**

The link between health care cost and quality of care is inconsistent across the spectrum of ages and disease processes. Much of the struggle lies in the heterogenous definitions of cost, quality, and value of care. While some studies (e.g., Kaempf Benefit Metric [44]) support a correlation between increased LOS (proxy for cost) and improved outcomes (neonatal morbidities), the literature either fails to look at the cost and quality in the same analysis or does not demonstrate a correlation. In addition, health care stewardship campaigns such as *Choosing Wisely* are built on the premise that eliminating services that are not necessary will not worsen outcomes (and potentially would improve them). Coupled with comparative reports such as *Mirror Mirror* [3], where the U.S. spends double or triple per capita on health care compared to economic equivalents ye<sup>t</sup> has worse outcomes, this combination suggests that there is room to reduce costs without negatively affecting outcomes (as has been demonstrated by multiple studies). The next steps for us to improve value in health care is to better define how we look at quality and costs in order to consistently study them together. As we strive to understand the variation in clinical outcomes, we must also strive to understand the variation in costs and embrace the opportunity to reduce each rather than assume that one hospital has better outcomes because they are resource rich and allocate higher dollars. In addition, we should include a "health equity lens" to ensure that our value-based care works to eliminate disparities between groups in health care and we are truly achieving improved outcomes for all of our patients.

**Author Contributions:** Conceptualization, D.D. and W.L.; literature review and initial draft preparation, L.C.; review and revision critically for important intellectual content, L.C., D.D., and W.L.; supervision, W.L. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Conflicts of Interest:** The authors declare no conflict of interest.
