As we move to a value-based model in healthcare, it is imperative we contemplate the dilemma of who is the ultimate risk bearer. At the conclusion of the day, that entity should be the one receiving the financial value of our efforts. Presently, the holder of the financial obligation for paying for services is not the recipient of the saved dollars. This is becoming increasingly prevalent as newer and exorbitantly expensive treatments are available that impact an illness earlier in the disease process. One might disagree with the premise that a certain level of healthcare is a right; nonetheless, we as a nation have effectively made this decision. For instance, deemed as illegal to refuse treatment of emergent care, people are not allowed to die at the footsteps of our emergency rooms based on ability to pay. Therefore, at the end of the day, our society is the ultimate risk bearer.
Now comes the conundrum, what is the definition of value to that risk bearer? Is it a purely financial one? Obviously not, as the ultimate cost effective alternative is completely unacceptable to us. Since a human life has greater value outside of pure dollars and cents, we do not and should not optimize the cheapest route. Therefore, the issue becomes how we measure that value as it relates to services needed. Do we consider it on an individual level or a societal level? These are the dualities we face. For instance, I visit the emergency room for a headache. I have no neurologic signs, nor is it the greatest debilitating pain I can imagine. In all likelihood, just to ensure that a life-threatening condition does not exist, I will receive a CAT scan of my head. As an individual, this is an excellent offering; yet awful from a societal perspective, as the likelihood of finding an issue is low, and resources have been used that might have gone to the care of others. Our present payment model does not tie those two facts together. At a macro level, if we assume there is only a finite pool of dollars, we can tie this CAT scan to a number of immunizations that could be given. Do I order the CAT scan or do I provide the immunizations? Is the quality regarding the individual or the group of individuals? Of course it depends on who is paying and what are the risks of not providing a service.
It is imperative that we as a society have these tough conversations. Life is the most precious gift we have been given and we need to ensure the discussions are within that realm. If we do not, eventually we will arrive at a point of commoditizing the nature of our existence. Sure, we need to be realistic within our construct; however, we need to move past viewing everything in a simplistic manner. Life is not simple, nor are the answers.