Medicine treats the evaluation of emerging technologies as a technical problem, but it is not. It is fundamentally an economic problem.

When does a ₹30,000 genetic test represent excellent value and when does it represent wasted money? The answer depends on a question members of the medical profession almost never discuss: who’s paying?

This distinction is critical in India, where millions of individuals make expensive healthcare decisions out of pocket while public health systems struggle with scarce resources and competing priorities. Yet this is precisely where thinking clearly matters most: your decisions directly affect your health and finances in ways that can’t be reversed or recovered from.

Unique vulnerability

A patient might spend ₹2 lakh on a recommended screening test that a government health system would never fund at scale — not because the test is bad but because the math works differently when you are an individual versus a system.

Yet patients rarely understand that they are trying to optimise for these incompatible situations. They simply spend money and hope it is the right decision.

Consider a genetic screening test for hereditary cancer risk in a woman with a family history of breast cancer. A positive test entails preventive surgery, significantly improved survival, lifelong surveillance, and critical family planning decisions. Here, ₹30,000 represents excellent value.

But deploy the same test in a healthy population and it is positive roughly twice per 1,000 healthy individuals. So you spend ₹3 crore identifying two individuals who benefit. The remaining 998 experience anxiety, unnecessary follow-up check-ups, and potential harm from false positives. The same test has opposite value depending on the context and who is paying, which is why these conversations are so fraught.

Return on investment

In India, patients and health systems evaluate the same technologies through fundamentally incompatible frameworks. An individual spending their own money asks “will this help me?”. A government with scarce resources asks “what is the return per rupee across the population?”.

These questions cannot have the same answer, yet patients need to understand both to make informed decisions.

Consider sophisticated cancer screening once again. A wealthy individual can afford ₹50,000 a year to catch one cancer earlier — which is an excellent personal return on investment. A government screening 1 lakh women would spend ₹500 crore and catch 20-30 cancers earlier. That quantum of money would be better used to treat patients already diagnosed rather than screen healthy people. The technology was identical but the value proposition was opposite.

As an individual, the technology is worth it if benefit exceeds cost. Your risk tolerance, values, and circumstances matter. You may rationally choose expensive screening that public health cannot justify at scale.

But is more expensive always better? Not quite.

Newer is not better

Healthcare differs from consumer goods because the stakes are permanent. You cannot undo an implant that causes chronic pain, reverse an unnecessary diagnostic test or erase a false diagnosis from your medical record. Expensive does not mean better in healthcare. It means higher stakes.

Rather than asking whether a treatment is worth the cost, let us ask more prudent questions. For example, does it produce meaningfully better outcomes than what already exists?

A robotic surgery might be more precise but does it actually improve function compared to traditional methods? Better precision sounds good until outcomes are identical at double the cost.

Consider minimally invasive diagnostic devices. A newer needle biopsy might require special equipment and training. But if both produce identical accuracy, and one takes 15 minutes while the other takes 45 minutes, the newer device effectively consumes resources without improving your diagnosis.

Newer isn’t better. Better is only when outcomes actually change.

Recovery burden

For newer cancer drugs, survival may improve by a few months but the cost and side-effect burden may be immense — sometimes ₹5-10 lakh a month versus ₹1-2 lakh for older drugs.

A drug extending one’s lifespan by three months while causing severe nausea, cognitive impairment, hair loss, inability to work, and requiring weekly hospital visits isn’t automatically superior to one extending life by two months with manageable side-effects that you can sustain at home.

An individual might gain 90 days of life but lose those days in hospital admissions and emergency department visits. Quality of life during treatment matters as much as survival statistics.

Long-term safety

Newer options appear attractive but established options are backed by decades of documented safety. A medication with 30 years of outcomes in millions of patients carries substantially less risk than one with three years of data in the hundreds. That history matters when you are considering putting something new into your body.

Another distinction that matters more radically is whether some technology has been approved for your specific condition or if it is being used off-label. Off-label use is legal in India; to make matters worse, evidence supporting it is often dramatically weaker than for approved indications.

A technology might be brilliant within its approved use and problematic outside it. For example, expandable metal stents approved for biliary ducts were used off-label in blood vessels, where different mechanical environments caused vessel rupture, cardiac complications, and at least 13 deaths before regulators intervened.

The device worked perfectly for its intended purpose. It failed catastrophically outside that context.

Being a good patient

Asking these questions doesn’t make you a difficult patient. It makes you an informed one. When your doctor recommends an expensive new technology, you don’t need to be confrontational. Write down the questions beforehand and don’t shy away from the hard ones.

Take notes on the answers. Good doctors welcome these questions because they have already asked themselves the same things. If a doctor dismisses your questions or pressures you into deciding immediately, that is important information. You deserve time to think through expensive decisions.

Medicine is not unique in requiring difficult trade-offs — but it is unique in the stakes. A bad stock investment recovers. A bad medical technology decision becomes part of your body, your medical record, and your life forever.

The questions that matter are not intellectually complex but they may feel uncomfortable to ask. Your responsibility is to ask them anyway, demand evidence and insist on comparison. In a system designed to innovate faster than it validates, your scepticism is your only real leverage.

Narayana Subramanian is Lead Consultant, Head and Neck Surgery and Oncology, Aster Hospitals, and Adjunct Faculty, Indian Institute of Science, Bengaluru.