In 2018 the FDA approved a record number of new products, but pharmaceutical R&D returns have fallen to their lowest level in nine years. Biotech IPOs are still strong in an overall weakening market, but federal investment in biomedical R&D, which feeds the product and start-up pipeline, has declined almost 20 percent in real terms since 2003. How should we collectively be measuring the success of our R&D investments, and how are investment behaviors incentivized across the biomedical ecosystem? Can the economic and societal benefits of biomedical innovation outputs—from basic science to patient access—be measured from the patient perspective?