Treatment Futures

A key problem in medicine is: what general process or institution can ordinary sick patients and concerned loved ones rely on to choose the best treatments (or none)?  They could rely on a doctor’s advice, but then how do they pick him or her, or be assured he or she has sufficient incentives to find and choose the best? 

A month ago I described one solution: health plans that "feel your pain" via payments designed to match your health value.  Today I’ll outline another solution: "treatment futures," i.e., decision markets where speculators can bet on your health, conditional on treatment decisions.   

Imagine a surgeon had recommended heart surgery for you, but you had doubts.  You could post an anonymized health record to the web, and let people bet on how many more years you will live if you did the surgery as suggested, and how many years if you did nothing for now.  Market estimates of those year numbers would tell you which option speculators thought best. 

You could use quality-adjusted years to make sure speculators considered disability and pain, and you could compare many options, such as different kinds of surgery or drugs and switching to a different surgeon.  And you could let your doctors, their associates, and your friends bet on you, as long as you made sure they kept a positive interest in your doing well.  As with college choice futures, most bettors would probably bet on bundles of patients, such as all 40 year old men with certain symptoms.   

Now while a heart surgery might have a big effect on years to live, most treatments have too small an effect to see clearly over market noise.  But you could bundle lots of small decisions into a big decision with a larger effect.  For example, you could ask about the choice of a health plan or doctor for the next year(s).  Also, if we bundled up decisions about many different patients who were comparing two particular doctors, hospitals, or plans, that could give us a good evaluation of the relative quality of those doctors, hospitals, or plans.   

The main problem I see is people being unwilling to believe the likely market advice that they should get a lot less treatment than most people now do.  I expect decision market advice will have to prove itself well in other areas before people will consider its advice about medicine, and even then I’m not sure people will listen. 

This post in response to a question by Alan Garber.  I first presented this concept at the RWJF Health Policy Scholar annual conference in 1999. 

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  • Floccina

    Robin after reading your work on healthcare, I needed to take my son to a have a minor procedure and I started asking the doctor some questions about the efficacy of the procedure. He got upset and accused me of being “in to natural medicine”, evidently most people who question him are “in to natural medicine”. I told him I was not and that I was insulted but I stopped asking question and let the procedure go forward as it seems to me to be clearly beneficial. I said that to show that I know how this will go over with the doctors but how about we insist that we pay the doctor over time only if there is a positive outcome.

    We could also treat doctors more like auto mechanics and insist that if the procedure does not work as described that they fix it again. With auto mechanics we do not always do this because sometimes there are additional thing that need to done to fix the problem but if a part that they replaced does not work we bring it back and they fix it free.

  • Ian

    Floccina, check out this NYTimes article: “In Bid for Better Care, Surgery With a Warranty”

  • Biomed Tim

    “We could also treat doctors more like auto mechanics and insist that if the procedure does not work as described that they fix it again.”

    One caveat: unlike the human body, humans designed cars so we know every single thing about how cars are supposed to work. Sometimes, procedures don’t work for unknown reasons.

  • Cassio

    A key problem in medicine is: what general process or institution can ordinary sick patients and concerned loved ones rely on to choose the best treatments (or none)? They could rely on a doctor’s advice, but then how do they pick him or her, or be assured he or she has sufficient incentives to find and choose the best?

    Actually, Robin, medicine nowadays is a quite standardized science. Sientific knowlege is widely accessible in our time, when internet offers information at hand for any doctor who has a minimum of interest to search for it. On the other hand, many different groups of researchers, supported by industry or by government, are constantly producing information and receiveing feedback from the medical community after new information on treatment options are set in practise. This constant dialogue between scientifical community and practitioners give birth to many different guidelines to diagnosis and treatment in many different specialities. Rarely, some doctors do not want to apply decisions following the guideline. If there is not a very good reason for it, medicare, insurance companies or any other source of payment for the treatment will not authorize the payment, since the given treatment effectivity was not scientifically proven and peer-reviewed.

    Giving medical advice when asked is the second part of it all. It is not something you can learn on stock market as a broker, or an investor. Giving medical advice is much more listening to what someone needs and, applying science and art (medicine is science, but it is art, too, and I am not talking about TV shows) trying to heal when possible and to ease every time. This can be taught, but probably not in the way you devise. If the doctor´s job was simply to process information without humanity, compassion and simpathy, and this resulted in good quality medicine, you bet that computers would be doing it by today – much better than humans.

    Scientifical medical information is produced in the context of studies on large populations, since the effect to be measured, as you said, is often very small to appear in a handful of individuals studies. For example, the total effect of some chemotherapy treatments, in unselected populations, is a 2% difference in outcomes (be, for exemple, general mortality in five years). Basic statistics show that it is necessary at least 50 people reciveing the treatment for the effect to appear, in a five-years follow-up. A little bit more advanced statistics teach us that the groups – since a control group is needed – shall be much larger, to annulate the efects of biases (factors that we don´t know or cannot control) and to balance the odds that the effect was, after all, only good luck.

    Finally, what you conceive is nothing more than the study of a population where n=1. Not much power to predict almost anything.

  • Cassio, my proposal is not intended primarily to promote or change research practice. As you note doctors and others disagree about treatment choices, and the goal is to create the best incentives to make the best choices.

  • Gabe

    Aha, but what about when people bet on poor outcomes for patients but the patients go on living? Perhaps we will see a spike in murders. What then!? 😉

  • Gabe, it is easy to limit how much a person could stand to gain from a patient’s death.

  • Jor

    Anybody who would post about their decision to a futures market probably already seeks multiple opinions before undergoing a large procedure / treatment. Although physicians aren’t staking money on their recommendations — this subset of sophisticated patients are most likely aggregating information from multiple knowledgeable physicians .

  • This is a better idea than paying for health, but it has one serious practical (not theoretical) limitation: there’s no data that would let the futures market do a better job than a doctor, or indeed, a simple google search. There’s little harm in implementing the market early, though, and it may speed the arrival of diagnostic tools that could actually provide useful data.

    Medicine is perhaps the only form of alchemy to survive the enlightenment (like all good alchemy, it is very good at appearances). I probably shouldn’t write that without a stronger stomach for the holy war that’s likely to follow, but there you go.

    Where the alchemy intersects with field (as in battlefield) medicine, things have improved (though hardly by means of science). If your problem can be fixed with a knife, you’re in good shape. Wars are out of fashion, however, and our medicine utterly fails to meet the disease of an industrial (let alone an information) economy.


  • Carl, doctors could be allowed to trade, so it could do as well as the best doctor willing to trade.

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