Value-Based Care Faces Ethical Scrutiny Over Patient Autonomy and Cost Burden

A recent social media post by Dr. Alex Shteynshlyuger, a board-certified urologist known for his patient-centered approach, has ignited discussion regarding the ethical complexities inherent in value-based care (VBC) models. Dr. Shteynshlyuger questioned the practical and ethical viability of VBC when patient preferences diverge from cost-optimized treatment pathways, specifically asking, "If a patient is given all reasonable options, and chooses the most expensive that may not be the most effective but has the fewer quality of life side effects, who pays for that choice? The surgeon?"

Value-based care is a healthcare delivery framework designed to incentivize providers based on patient health outcomes and overall quality of care, rather than the volume of services rendered. Its core objectives include enhancing patient experience, improving health outcomes, advancing health equity, and delivering services at a reasonable cost. This model aims to shift the focus from a fee-for-service system to one that prioritizes efficiency and measurable results.

However, Dr. Shteynshlyuger's tweet highlights a critical ethical dilemma at the intersection of VBC principles and patient autonomy. While VBC often emphasizes clinical effectiveness and cost-efficiency, individual patients may prioritize quality of life, comfort, or personal values that lead them to choose more expensive treatments, even if alternative, less costly options are medically "effective" in a narrow sense. This scenario pits the VBC's outcome-cost ratio against the patient's right to self-determination and the principle of beneficence, which dictates acting in the patient's best interest.

The question of who bears the financial responsibility for such patient-driven choices remains a significant challenge within the VBC framework. If providers are penalized for treatments that do not align with VBC's cost-efficiency metrics, it could create a disincentive to offer or support patient choices that enhance quality of life but are not the most economical. This tension underscores a broader debate within healthcare: balancing population-level cost control with the nuanced, individual needs and preferences of patients.

Experts suggest that a more "Values-Driven Health Care" approach may be necessary, one that broadens the definition of "value" beyond mere outcomes-to-cost ratios to encompass patients' personal values, intrinsic aspects of care, and fosters greater trust between professionals and patients. The ongoing discussion emphasizes the need for healthcare systems to navigate these ethical complexities to ensure that cost-efficiency does not inadvertently compromise patient-centered care and individual well-being.