Paying for one-time cures in a system built for chronic care.

A one-time curative therapy can replace years of disease burden: the clinic visits, the informal caregiving, the lost work, the rehabilitation. That is exactly why it can carry a high one-time price. But health systems pay the way they were built to pay — in steady streams, for chronic care — and the person or plan that pays on day one is rarely the one who collects the savings. Those land with patients, families, employers, disability and rehabilitation programs, and the public purse.

So the central question is not only whether a therapy works. It is how a health system converts long-duration value into a payment stream that is affordable, credible, and fair — without quietly rationing cures that work.

Financing cures means spreading cost and risk over time and across many patients — which is structured finance, and structured finance carries the shadow of the 2008 mortgage crisis. My starting point is simple: treat 2008 as a floor, not a ceiling. The crisis is not the limit of what pooled financing can be. It is the minimum set of lessons any new structure has to beat before it deserves trust.

What actually failed in 2008 was not the idea of pooling. It was everything around it:

• Misaligned incentives — originators were paid to make loans, not to make good ones.
• Weak underwriting — nobody checked whether the underlying asset could perform.
• Mispriced correlation — the models assumed failures would arrive one at a time. They arrived together.
• Opacity and leverage — risk was sliced, re-sliced, and hidden until no one could see inside the pool.

Each failure becomes a design requirement. If a financing structure for curative therapies cannot show how it answers all four, it has not cleared the floor.

The research develops and stress-tests a population-level structure — the Vision Restoration Outcomes Pool — built on principles chosen to beat the 2008 floor:

• Payments follow outcomes. Money moves when independently verified results say the therapy is still working — durability and functional independence, measured by people with no stake in the answer.
• Risk is pooled, honestly. Costs are spread across patients, payers, and time, with the correlation between failures priced in instead of assumed away.
• Transparency by construction. Clear contractual waterfalls, audit rights, and no re-packaging of the pool into something nobody can inspect.
• Aligned incentives. Manufacturers stand behind durability; payers share in verified success; nobody gets paid for volume alone.
• Stress-tested, not sales-tested. The structure is modeled against correlated treatment failures, payer or manufacturer distress, and bad macroeconomic years — before anyone is asked to rely on it.

The study does not presume this structure beats simpler options like installments or straightforward outcomes-based contracts. Its value has to exceed its complexity — that comparison is the research.

The first application is vision. Inherited retinal diseases can take sight during working age, and the cost is mostly not medical: it is lost earnings, lost independence, caregiving, and rehabilitation. Retinal cell and gene therapies now offer the possibility of preserving or restoring sight — which makes vision restoration the cleanest place to test whether outcomes-based financing works, because the return is visible in a person's life: traveling independently, keeping a job, needing less help.

Clinical and functional outcomes govern payment for each patient. The wider effects — employment, rehabilitation savings, caregiver relief — are measured at population level, as shared value. They are never a condition of any individual's access to treatment.