Health care costs continue to rise, yet the conversation about why often feels like a loop. Hospitals point to insurers. Insurers point to hospitals. Pharmacy benefit managers cite manufacturers. Manufacturers point back across the system. Meanwhile, patients are left trying to make sense of bills that feel disconnected from the care they received. In Massachusetts, often viewed as a national model for health care coverage, the average total cost of care for a family now exceeds $31,000 per year.

And despite near-universal coverage, affordability remains a growing challenge. More than 40 percent of Massachusetts residents report struggling with health care costs, including medical debt, delayed care, and difficulty affording needed services, according to the Center for Health Information and Analysis. Out-of-pocket costs are rising quickly. In just a few years, average spending has increased nearly 30 percent, and the number of residents paying more than $5,000 annually has doubled. Even in one of the most advanced health care systems in the country, costs are rising faster than wages and exceeding the state’s sustainability benchmarks.

The structural challenge of health care fragmentation

It is a frustrating dynamic. It is also a revealing one. The reality is that no single sector is solely responsible for rising health care costs. The challenge is structural. We are asking a fragmented system, where each stakeholder is optimizing for its own incentives, to somehow deliver affordability, access, and quality simultaneously. Costs are not reduced so much as they are shifted. Complexity increases. Trust erodes.

If a state with near-universal coverage and strong oversight is struggling to contain costs, it is clear that no single stakeholder can solve this alone. If fragmentation is the problem, collaboration must be the solution. That collaboration cannot be superficial. It cannot be limited to periodic discussions or industry panels that diagnose the problem without changing the outcome. What we need instead are regional, cross-sector collaboratives that bring together providers, insurers, employers, pharmaceutical stakeholders, and policymakers to take on a shared responsibility.

These collaboratives must do more than talk. They must set shared goals for cost growth and patient outcomes. They must define common metrics that allow progress to be measured consistently across organizations. And they must commit to transparency, including regular public reporting on results.

Why accountability in health care is no longer optional

This idea often runs into a familiar objection: No one will voluntarily take on more accountability. It is an understandable concern. Transparency can be uncomfortable. Shared metrics can expose inefficiencies. And in a system where margins are tight and pressures are high, the instinct is often to protect, not to open up. But this argument overlooks a fundamental shift that is already underway. Accountability is no longer optional.

Employers are demanding greater visibility into the cost and value of care as they struggle to manage rising benefit expenses. Policymakers are increasing scrutiny and advancing new requirements around price transparency and cost control. And patients, who are paying more out of pocket than ever before, are asking harder questions and making more difficult choices, including delaying or avoiding care altogether.

In other words, accountability is already here. The problem is that it is being applied in fragmented and inconsistent ways that often add complexity without improving outcomes. The question is not whether we will be held accountable. The question is whether we will shape that accountability together or have it defined for us.

Building regional cross-sector collaboratives

Organizations that step into this space early have an opportunity to help define the standards. They can influence what gets measured, how success is determined, and how progress is communicated. Those that do not will still be part of the system, but they will be reacting to frameworks built by others, often without the benefit of shared context or aligned incentives.

Cross-sector collaboratives offer a path forward. They create a structure where stakeholders can align around shared goals, track progress using common metrics, and take collective ownership of results. This is not about eliminating competition or ignoring the real differences between sectors. It is about recognizing that an unaffordable system for patients is unsustainable for everyone within it.

To be effective, these efforts must be grounded in execution:

• Shared regional targets must be clear and measurable.
• Metrics must be consistent and meaningful.
• Transparency must be real, not symbolic.

Without these elements, collaboration becomes conversation. With them, it becomes a mechanism for change.

Moving beyond discussion to shared responsibility

Health systems play an important role in this work. We sit at the intersection of care delivery, patient experience, and community health. We see firsthand how fragmentation affects patients, not just financially, but emotionally and physically as they navigate an increasingly complex system. But leadership in this moment is not about control. It is about convening. It is about bringing the right stakeholders to the table and being willing to rethink long-standing assumptions about how the system operates. It is also about recognizing that no single organization, no matter how well-positioned, can solve this problem alone.

The path forward will not be easy. It will require trust, discipline, and a willingness to move beyond assigning blame and toward accepting shared responsibility. But the alternative is to continue on our current path, where costs rise, confusion grows, and patients are left to navigate the consequences on their own. That is not sustainable. And it is not acceptable.

It is time to move beyond discussion and toward structure. We should establish regional, cross-sector collaboratives that bring together providers, insurers, employers, and policymakers to set shared cost and outcome targets, and to hold each other accountable for meeting them. Not incrementally. Not eventually. Now. Because the future of health care will not be defined by who is right in today’s debate. It will be defined by who is willing to work together to build something better.

Christine Schuster is a nurse executive and hospital CEO.