Healthcare Needs a Sixth Gear

A System That Needs More Than Harmony

Healthcare is a complex system with no shortage of ambition — to cure, to care, to serve. Yet despite this shared mission, progress is often slow, fragmented, and filled with friction. In It Takes Five to Tango, Dr. Verena Voelter paints a vivid picture of why this is the case: transformation in healthcare requires all five key players — the Patient, the Payer, the Provider, the Policymaker, and Pharma — to move in step like dancers in a delicate tango.

Her book is both a diagnosis and a call to action: we won’t achieve sustainable, value-driven healthcare until these five stakeholders stop working in silos and start co-creating real change.

Reading it, I felt both inspired and restless. Inspired by her clarity. Restless because something still felt missing — a kind of invisible player, one I encounter every day in my work with startups, hospitals, insurers, and researchers. One that isn’t officially invited to the dance floor, but often leads the first steps of transformation.

So I’d like to make a proposal: let’s expand the model. Let’s add a sixth P — the Pioneer.

The 5Ps of Healthcare: A Valuable but Incomplete Map

Dr. Voelter’s framework revolves around five core actors, each essential yet often disconnected:

• Patient – The ultimate beneficiary, yet frequently the least empowered voice.
• Payer – Insurers and reimbursement bodies that shape what care is economically viable.
• Provider – Hospitals, clinicians, and care teams delivering frontline services.
• Pharma – The engine of biomedical innovation, driving new therapies and technologies.
• Policymaker – Governments and regulators setting the rules of the game.

Together, these five Ps form the foundational structure of any health system. Voelter’s insight is that no single P can drive transformation alone. Collaboration is not optional — it is the only way forward.

But here’s the tension: while these five actors hold power and responsibility, they are also bound by their own constraints — legacy infrastructure, risk aversion, budget cycles, institutional inertia. As a result, bold innovation rarely originates within the 5Ps. It’s negotiated, delayed, sometimes diluted.

This is not a critique of the model — it’s a recognition of its limits.

The Missing Force: Why We Need a Sixth P

While the 5Ps define the structure of the system, they often struggle to initiate meaningful change from within. And yet, innovation does happen. It bubbles up from unexpected places. It’s driven by individuals and teams who aren’t waiting for permission — they're building, testing, and sometimes breaking the rules to move things forward.

In my experience, the first sparks of transformation often come from people and organizations that don’t fit neatly into any of the five Ps:

• Startups with radically new approaches to diagnostics or patient engagement.
• Academic teams spinning out applied research with commercial potential.
• Intrapreneurs within hospitals or payers experimenting with new care pathways.
• Tech vendors building tools that challenge how care is delivered or reimbursed.

These actors don’t just "support" the system — they push it. They fill in the white spaces, tackle the unsolved, and take risks the incumbents can't afford. Yet, they're often seen as outsiders or "nice-to-haves", rather than integral to the system's evolution.

And that’s precisely why we need to acknowledge them formally — not just as innovators, but as structural agents of change. We need a sixth seat at the table. We need the Pioneer.

Introducing the Pioneer: The Sixth P

The Pioneer is not a single entity — it’s a mindset embodied by those who challenge the status quo from within or alongside the healthcare system. Pioneers are driven not by entitlement, but by urgency. They are the first to see that "good enough" isn’t good enough — and they act.

Pioneers include:

• Startups crafting digital health tools, AI diagnostics, or novel care models.
• Vendors enabling new workflows, patient journeys, or reimbursement pathways.
• Intrapreneurs inside insurers or hospitals, designing pilots from the ground up.
• Academics translating breakthrough science into deployable solutions.

What unites them is not where they sit, but how they operate: agile, cross-disciplinary, often underfunded — but fiercely committed to solving real problems. They experiment. They prototype. They fail fast. And when successful, they make the impossible suddenly seem inevitable.

At Future of Health Grant, we see this every day. Pioneers bring not only innovation, but energy. They create momentum that can pull the other 5Ps into motion. But for that to happen, they need recognition, access, and above all — collaboration.

Because when a Pioneer succeeds, it's not just their win. It's a win for the whole system.

From Competition to Co-Creation: Towards a 6P Tango

The original “5P Tango” metaphor captures the intricate choreography of the healthcare system — each actor with its own rhythm, its own constraints, yet ultimately dancing together toward a common goal. But today’s reality demands more than coordination — it demands co-creation. And that’s where the Pioneer changes the dance.

Pioneers aren’t just new dancers — they’re often the ones designing the music, the steps, or even the stage. But for their contributions to have lasting impact, we need to make space for them in the system — not as outliers, but as integrated partners in innovation.

This means:

• Inviting Pioneers early into policy discussions, pilot designs, and reimbursement pathways.
• Creating shared metrics that bridge startup speed and systemic safety.
• Funding mechanisms that reward experimentation without punishing failure.
• Cross-sector platforms, like the Future of Health Grant, that broker real collaboration between insurers, startups, providers, and regulators.

Co-creation doesn’t erase power asymmetries — but it can soften them. It doesn’t solve misaligned incentives — but it makes misalignment visible. Most of all, it reframes innovation as a collective responsibility, not a competitive advantage.

A 6P Tango may be harder to coordinate, but it’s the only dance that reflects the complexity — and the opportunity — of modern healthcare.

A More Complete Dance

Verena Voelter’s It Takes Five to Tango is a vital reminder that transformation in healthcare is not about heroics — it’s about alignment. But alignment doesn’t mean rigidity. It means making room for those who move differently, who take the first risk, who provoke the system to evolve.

That’s why we need the Pioneer. Not as an afterthought, but as a sixth, essential force. One that thrives on experimentation, connects silos, and builds what others only imagine.

Adding a sixth P isn’t about breaking the model — it’s about completing it.

If we want healthcare to become more inclusive, agile, and value-driven, we need to recognize that innovation doesn’t just happen within systems. It often happens between them — in the messy, creative spaces where Pioneers work.

The question isn’t whether the Pioneer belongs at the table.

The question is: can the system afford to leave them out?