More on UNOS in the hot seat and calls for reform of the U.S. deceased donor transplant system

 Here's another report about the recent Senate Finance Committee hearing about UNOS, which includes a redacted version of the U.S. Digital Service report calling for UNOS's functions to be broken up. (UNOS, the United Network for Organ Sharing, is the federal contractor that runs the U.S. deceased donor transplant system.)

Transplant System Urgently Needs Overhaul, Experts Say— UNOS CEO skewered for alleged failures in management during a Senate Finance Committee hearing by Shannon Firth, Washington Correspondent, MedPage Today

"Members of the Senate Finance Committee and fellow witnesses roasted the head of the United Network for Organ Sharing (UNOS) during a hearing on Wednesday, over what Committee Chair Ron Wyden (D-Ore.) characterized as "gross mismanagement and incompetence."

...

"A report from the U.S. Digital Service issued last year determined that the network lacks the technical capacity to modernize the system. The report recommended that the contract for the system, worth $248 million, be separate from a contract for policy management, according to The Washington Post.

"Sen. Elizabeth Warren (D-Mass.), not one to mince words, told Brian Shepard, CEO of UNOS, "I'll just be clear. You should lose this contract. You should not be allowed anywhere near the organ transplant system in this country. And if you try to interfere with the process of turning the contract over to someone who can actually do the job, you should be held accountable for that."

HT: Frank McCormick

**********

And here is a Senate memo issued just prior to the hearing:

“A System in Need of Repair: Addressing  Organizational Failures of the U.S.’s Organ Procurement and Transplantation Network”

"This bipartisan investigation began in February 2020 when then-Chairman Charles Grassley, then-Ranking Member Ron Wyden, Senator Todd Young, and Senator Benjamin Cardin sent a letter to UNOS expressing their concerns about the adequacy of patient safety standards and belief that OPOs are failing to recover thousands of viable organs each year. 16 The letter also highlighted an investigation by the Department of Health and Human Services, Office of Inspector General (HHS OIG) and news reports, shining a light on “lapses in patient safety, misuse of taxpayer dollars, and tens of thousands of organs going unrecovered or not transplanted,” leading to questions about the adequacy of UNOS’ oversight of OPOs.”17

"In 2021, the investigation continued under the leadership of now-Chairman Wyden and Ranking Member Grassley of the Senate Judiciary Committee with a series of bipartisan requests for information sent to HHS,18 CMS,19 HRSA, and the Office of Management and Budget. Staff also broadened the scope of the investigation to include concerns about the inadequacy of the OPTN information technology system and its impact on patients. 

...

Based on documents and internal memoranda, the Committee found that:

• The OPTN is failing to provide adequate oversight of the nation’s 57 OPOs, resulting in fewer organs available for transplant.

• The lack of oversight by UNOS causes avoidable failures in organ procurement and transplantation resulting in risks to patient safety. These failures include testing procedure errors, transportation issues resulting in life saving organs being lost or destroyed in transit, and process and procedure failures.

• UNOS lacks technical expertise to modernize the OPTN IT system, resulting in risk of system interruption or technical failure with the potential to harm patients across the country."

...

"While not the sole focus of the Committee’s investigation, Senator Grassley and Senator Wyden’s staff also heard concerns from patients, transplant center staff, and OPO staff that UNOS lacks technological expertise or the willingness to develop and maintain an adequate IT infrastructure. Staff also heard concerns that the archaic IT system results in delays in placing organs, organs being discarded, and inaccurate data being used to place organs because of its dependence on staff manually entering hundreds of donor and transplant candidate data points rather than upgrading to systems better able to transfer data across Electronic Medical Record platforms.

"These concerns were validated in a report from the independent U.S. Digital Service (USDS), which is housed within the Executive Office of the President and provides consultation services to federal agencies on information technology.115 The report, titled Lives Are at Stake, states that UNOS has been able to wiggle through and around most new contract requirements for the OPTN technology by hand-waving at change with technical jargon, while making no substantive progress. The USDS also states that:116

• UNOS is incapable of modernizing the OPTN IT infrastructure;

• the core systems are fragile;

• OPTN technology limits policy development;

• UNOS is resistant to change; and,

• OPTN system is dependent on a disjointed and inadequate user experience.

"Ultimately, USDS determined that these technological failings are in fact placing lives at stake and recommended that HHS take action to create a better organ transplant system and enable better patient outcomes, including updating NOTA to create flexibility in how the OPTN is serviced by contractors."

...

"Based on the investigation’s findings, Committee staff makes the following recommendations to improve the OPTN:

• Remove barriers to competition by removing the specific requirement for HHS to contract only with a “non-profit entity that has an expertise in organ procurement and transplantation;”

• Increase the pool of potential bidders by clarifying that the OPTN functions described in NOTA and subsequent amendments may be operated by more than one contractor, since few contractors will have adequate clinical knowledge and expertise in IT, policy development, and data collection and reporting, and policy compliance activities;

• Promote innovation in all OPTN functions (e.g., policy development, compliance and patient safety mentoring, IT infrastructure, coordinating transport of organs, etc.) as the best qualified entities with distinct skill sets could compete for contracts for these functions;

• Remove a major barrier for entry for bidders by providing authority for HHS to procure a government owned, contractor operated modern IT system to facilitate the OPTN functions;

• Increase security and innovation in the OPTN system by ensuring the new IT system is based on current technologies and operated and maintained by a contractor with adequate IT knowledge and experience;

• Ensure the continued viability of the OPTN by authorizing HHS to collect fees from transplant hospitals when adding a patient to the national organ transplant waitlist. This would replace a current fee structure authorized by regulation which is not flexible enough to provide funding for multiple contracts;

• Increase transparency and accountability for chain of custody and transportation of organs procured for transplant by providing for public reporting, as appropriate, on the status of organs in transport; and,

• Increase accountability for organs lost, damaged, or delayed in transport by requiring oversight and corrective action for such incidents.

**********

Earlier:

Wednesday, August 3, 2022

UNOS and organ transplant technology

Thursday, August 4, 2022

UNOS hearing in the Senate

MATCH-UP 2022, August 24-26, 2022, TU Vienna, Vienna, Austria

 MATCH-UP 2022, August 24-26, 2022, TU Vienna, Vienna, Austria

registration for the workshop is only possible until August 16, 23:59 CET: https://www.eventbrite.at/e/match-up-2022-the-6th-workshop-on-preferences-under-matching-registration-368493533077

Here's the program:

24.08. Wednesday

13:30–14:15		Registration
14:15–14:30		Opening remarks
14:30–14:55	Estelle Cantillon, Li Chen and Juan Pereyra	Respecting priorities versus respecting preferences in school choice: When is there a trade-off?
14:55–15:20	Lars Ehlers	Student-Optimal Interdistrict School Choice: District-Based versus School-Based Admissions
15:20–15:45	Bnaya Dreyfuss, Ofer Glicksohn, Ori Heffetz and Assaf Romm	Incorporating Reference-Dependence Considerations in Deferred Acceptance
15:45–16:15		Coffee break
16:30–16:55	Xuan Zhang and Yuri Faenza	Affinely representable lattices, stable matchings, and choice functions
16:55–17:20	Kemal Yildiz and Ahmet Alkan	Modular stable matching mechanisms
17:20–17:45	Peter Biro and Gergely Csáji	Strong core and Pareto-optimal solutions for the multiple partners matching problem under lexicographic preferences
17:30–19:30		Poster session

25.08. Thursday

9:00–9:25	Niclas Boehmer, Klaus Heeger and Stanisław Szufa	A Map of Diverse Synthetic Stable Roommates Instances
9:25–9:50	Klaus Heeger and Ágnes Cseh	Popular matchings with weighted voters
9:50–10:15	Inbal Rozenzweig, Reshef Meir and Nicholas Mattei	Mitigating Skewed Bidding for Conference Paper Matching
10:15–10:40	Sai Srivatsa Ravindranath, Zhe Feng, Shira Li, Jonathan Ma, Scott Kominers and David Parkes	Deep Learning for Two-Sided Matching
10:40–11:10		Coffee break
11:10–11:35	Yannai Gonczarowski, Ori Heffetz and Clayton Thomas	Self-Explanatory Strategyproof Mechanisms
11:35–12:00	Assaf Romm, Alvin Roth and Ran Shorrer	Stability vs. No Justified Envy
12:00–12:25	Rupert Freeman, Geoffrey Pritchard and Mark Wilson	Order Symmetry: A New Fairness Criterion for Assignment Mechanisms
12:25–14:00		Lunch break
14:00–15:00	Keynote: Vijay Vazirani Note: Different from the other talks, will be held in Hörsaal 1 (lecture hall 1).	Online Bipartite Matching and Adwords
15:00–15:25	Danny Blom, Bart Smeulders and Frits Spieksma	Rejection-proof Kidney Exchange Mechanisms
15:25–15:50	Peter Biro, Flip Klijn, Xenia Klimentova and Ana Viana	Shapley-Scarf Housing Markets: Respecting Improvement, Integer Programming, and Kidney Exchange
15:50–16:30		Coffee break
16:15–16:40	Josue Ortega and Thilo Klein	Improving Efficiency and Equality in School Choice
16:40–17:05	Ran Shorrer and Sandor Sovago	Dominated Choices in a Strategically Simple College
17:05–17:30	Daniel Kornbluth and Alexey Kushnir	Undergraduate Course Allocation through Pseudo-Markets
17:30–18:00		Group photo in front of the main university building (Karslplatz)
18:30–22:00		Bus ride to and dinner at Heuriger

26.08. Friday

9:00–10:00	Keynote: Sophie Bade Held in Hörsaal 8 (lecture hall 8).	TBA
10:00–10:25	Nick Arnosti, Carlos Bonet and Jay Sethuraman	A Systematic Approach to Selection Problems
10:25–10:50	Di Feng, Bettina Klaus and Flip Klijn	A Characterization of the Coordinate-Wise Top-Trading-Cycles Mechanism for Multiple-Type Housing Markets
10:50–11:20		Coffee break
11:20–11:45	Haris Aziz and Zhaohong Sun	Multi-Rank Smart Reserves
12:45–12:10	Jean-Jacques Herings and Yu Zhou	Equilibria in Matching Markets with Soft and Hard Liquidity Constraints
12:10–13:45		Lunch break
13:45–14:10	Karolina Vocke	Anonymity and stability in large many-to-many markets
14:10–14:35	Kristóf Bérczi, Erika Renáta Bérczi-Kovács and Evelin Szögi	A dual approach for dynamic pricing in multi-demand markets
14:35–15:00	Georgy Artemov, Yeon-Koo Che and Yinghua He	Stable Matching with Mistaken Agents
15:00–15:25	Federico Bobbio, Margarida Carvalho, Andrea Lodi, Ignacio Rios and Alfredo Torrico	Capacity Planning in Stable Matching: An Application to School Choice
15:25–16:00		Coffee break
16:00–16:25	Haris Aziz, Anton Baychkov and Peter Biro	Cutoff stability under distributional constraints with an application to summer internship matching
16:25–16:50	Kenzo Imamura and Yasushi Kawase	Efficient matching under general constraints
16:50–17:15	Zheng Chen, Bo Li, Mingming Li and Guochuan Zhang	Fair Graphical Resource Allocation with Matching-Induced Utilities
17:15–17:40	Bo Li, Fangxiao Wang and Yu Zhou	Maximin Share Fair Allocation of Indivisible Chores: Beyond Additive Valuations
17:40		Closing remarks

Are sociology and economics coming closer together? Philippe Steiner in Acta Oeconomica

 Professor Philippe Steiner, of the Groupe d’Etudes des Méthodes de l’Analyse Sociologique de la Sorbonne, thinks that these days sociology and economics may be coming closer to each other than they have for some time.

New economic sociology and economic theory by Philippe Steiner, Acta Oeconomica 72 (2022) S1, 23–40  DOI: 10.1556/032.2022.00017

"Abstract: The paper begins with a brief reminder of the origin of economic sociology. It then surveys research by economic sociologists from the 1980s to the present, with a focus on their relation to political economy, which ranges from close to arm's length. Finally, beyond any differences between economic theory and economic sociology, the paper considers how both approaches can be connected in the socio-historical and economic study of economic inequalities by Thomas Piketty, and the use of matching markets by Alvin Roth."

...

"In the final part the paper seeks to show that economists have developed approaches that permit a fruitful combination of sociology and political economy, even using some of the more technical aspects of modern economics.

...

"After the 1930s economic sociology lost its appeal for economists, as well as sociologists, and gave way to the “Parsonian peace” according to which economists deal with value, while sociologists deal with values (Stark 2009: 7).

...

"There was a revival of economic sociology during the 1970s on both sides of the Atlantic. In the United States, this began with Mark Granovetter’s work on the labor market (Granovetter 1974), and then with a new interpretation of the social embeddedness of the market (Granovetter 1985). This was something that Polanyi had stressed in his book, noting the catastrophic consequences that follow the management of humanity, nature and politics as if they were market goods (labor, land and money) regulated by “supply and demand” in their respective markets. In the same period, Viviana Zelizer (1979, 1985) brought the sociology of culture closer to the sociology of economic life. In Europe, Pierre Bourdieu proposed a new interpretation of the market for cultural goods (or symbolic goods), to explain the functioning of the art market (Bourdieu 1971).

"As regards the relation to economic theory, the new economic sociology unfolds along four axes: (i) Granovetter established a close and direct relationship between economic sociology and the neo-classical theory of job search, together with the theory of transaction costs; (ii) Zelizer distanced herself completely from economic theory, although her sociology of economic life deals with central economic phenomena such as insurance, money, and law; (iii) Neil Fligstein developed an economic sociology close to institutionalist political economy, focusing on key institutions of the market, notably those regulating competition; finally, (iv) Bourdieu employed an original conceptualization of fields in order to explain the functioning of the markets of symbolic goods (fashion, painting, literature), while at the same time developing a methodological criticism of economic theory.

...

"In the case of the creation of the life insurance market in the United States, Zelizer started from the following paradox: while changes in social structure – fewer landowners, less mutual aid between neighbors – made it increasingly rational to insure one’s life to avoid leaving one’s wife and children destitute in the event of premature death, the life insurance market remained sluggish during the 19th century compared to what it was in Great Britain and in France. How do we explain this apparent lack of self-interested behavior in American male breadwinners? Zelizer’s answer employed several cultural arguments, including one based on the relationship to religion. During this period there was a widespread idea that to insure oneself against premature death was to oppose the will of God, even to not trust his wisdom. This was the reason for the reluctance to accept this new market product, the life insurance contract. A strength of her argument is also that she is careful not to oppose social behavior and self-interested economic behavior head-on. In fact, two phenomena directly linked to religion intervene to modify this cultural relationship to life insurance. First, she points to the fact that the religious sects that sent pastors to frontier regions took out life insurance on them so that the sect would not have to take care of their families if they died – a financial interest played its part in religious institutions. Second, she notes a reversal in the religious discourse on life insurance. In the beginning of the 20th century not only preachers, but also the rhetoric of insurance salesmen emphasized that the good father is he who takes precautions against premature death, hence this good father must be insured. Both culture and the economy began to structure behaviors that promoted a developing insurance market.

...

"While economists continued to employ the hypothesis of rationality, this is no longer central to the discourse of economic sociologists; the idea that economists are remote from the historical and social dimension has also lost its intensity. Instead, other criticisms have emerged, especially associated with the idea of performativity. At present there is neither conflict, or mutual indifference. Indeed, in several fields there are signs of an explicit or implicit rapprochement. I would like to mention two in particular.

"First of all, given the capacity of modern computers to process large databases, economists can deploy econometric tools in ways that accurately account for historical and social facts, as Thomas Piketty (1998, 2013, 2019) does. Second, by pursuing the strategy of economic engineering proposed by Alvin Roth (2002), economists take up the practical work of constructing institutions of exchange, exemplified by design economics and matching markets economists, developing what sociological economists have called the economic performation of the economy by economics (Callon 1998; MacKenzie et al. 2007)"

**********

Earlier

Thursday, January 6, 2022

The design and performation of markets: a discussion, by Michel Callon and Alvin Roth in the AMS Review

MEDIEVAL MATCHING MARKETS by Lars Boerner and Daniel Quint

 As I'll explain below, here's a long-awaited paper that fully qualifies for that description:

MEDIEVAL MATCHING MARKETS by Lars Boerner and Daniel Quint, International Economic Review, First published: 15 July 2022 https://doi.org/10.1111/iere.12600

Abstract: We study the regulation of brokerage in wholesale markets in premodern Central Western Europe. Examining 1,804 sets of rules from 82 cities, we find brokerage was primarily a centralized matchmaking mechanism. Brokerage was more common in towns with larger populations, better access to sea ports and trade routes, and greater political autonomy. Brokers' fee structures varied systematically: price-based fees were more common for highly heterogeneous goods, quantity-based fees for more homogeneous goods. We show theoretically that this was broadly consistent with total surplus maximization, and that brokerage was more valuable in markets with unequal numbers of buyers and sellers.

...

"We investigate how societies organized markets and whether their market policies were well designed to have a positive effect on welfare. We look at one important type of regulated allocation process, the organization of intermediation in the form of brokerage, primarily in wholesale markets. Regulated intermediation first appeared in European towns during the second half of the 13th century. Early regulations can particularly be found in Italy and the Lower Countries (van Houtte, 1936; Rezzara, 1903). However, a comprehensive quantitative study on the origin, spread and development of the brokerage institution is missing so far. Origins of brokerage have been linked to the urbanization process of the 13th century (van Houtte, 1936); whether it can be related to preceding medieval Arabic merchant institutions or Roman law is an open debate (van Houtte, 1936; Lieber, 1968).

"We study 231 cities in Central and Western Europe, roughly in the area of the Holy Roman Empire north of the Alps, during the period from 1200 to 1700. This area and period are particularly appealing for empirical investigation because local municipalities were typically economically and politically autonomous. Thus, each city could implement its own types of regulations and allocation mechanisms, leading to potentially rich variation in detail.

"We identify cities with (and without) brokerage regulations and find in cities with regulations a dominant brokerage design with specific combinations of rules. The dominant design was a sort of centralized matchmaking mechanism: a few licensed brokers specializing in a particular product were given the exclusive right to offer a service pairing mainly foreign merchants with local buyers, and their behavior was strictly regulated. Brokers were not allowed to do any business on their own behalf and were restricted in what information they could disclose. The brokerage service was open to everybody, to the rich and poor, and to foreign and local merchants. Brokers received a predefined fee based on the transactions they generated—most commonly either a fixed fee per unit traded or a fixed fraction of the sales price."

**********

I normally don't blog about papers twice, i.e. if I've blogged about the working paper I don't blog again about the published paper.  But this one has changed since I first blogged about it, and it implicitly tells us something about the current (but still medieval) publication system in Economics, since that was more than a decade ago. Here's the earlier (2011) blog.

Wednesday, February 16, 2011

Medieval Matching Markets

Pharmacy Benefit Managers--Alex Chan on NPR's Planet Money podcast

 Alex Chan is interviewed on the role of pharmacy benefit managers, their role in drug pricing, and some problems with the market design.

Do repugnant markets corrupt society? Kim Krawiec calls for evidence...

 Kim Krawiec, who studies taboo trades from a legal perspective, thinks that people who claim that repugnant transactions undermine society should be asked to provide evidence.

Krawiec, K. (2022). Markets, repugnance, and externalities. Journal of Institutional Economics, 1-12. doi:10.1017/S1744137422000157

Abstract: This Article considers one aspect of the ongoing debate about the moral limits of markets – namely, the purported harmful effects of market transactions on particular relations, goods, services, or society at large, due to an inappropriate valuation. In other words, the argument is that some markets are ‘repugnant’ because they degrade and corrupt a variety of nonmarket values and relations, not just to the willing parties to the exchange, but to larger segments of society. This objection contains both a (frequently unacknowledged) empirical component and a moral component. This Article critiques these empirical claims on two grounds. First, market skeptics fail to provide evidence of the negative effects they hypothesize, despite widespread variation over time and across legal regimes. Second, these objections fail to account for the well-documented human tendency to fashion repugnant exchanges in a manner that reinforces – rather than undermines – deeply held values and relationships.

...

"how do we, as a society, determine what is up for sale and what must be immune from market forces? Although all cultures and time periods have proclaimed some transactions too sacred for the marketplace, those boundaries vary greatly across times and cultures and are often contested at the margins (Fiske and Tetlock1997). Once-common practices such as slavery, commutation (a direct payment to the government in exchange for relief from military service), substitution (paying another for military service in one's place), and the purchase of indulgences are no longer acceptable in most societies ( Krawiec2009a; NY Times, 1864). At the same time, formerly taboo practices, such as charging interest on a loan or accepting money in exchange for the practice of law are now widespread – although, in the case of charging interest, not universally so (Rossman2014).

...

"Many justifications have been offered for limits on ‘repugnant’ (Roth 2007) or ‘taboo’ ( Fiske and Tetlock1997) markets. This article considers a single, but prominent, objection – that some markets degrade and corrupt a variety of nonmarket values and relations, not just to the willing parties to the exchange, but to larger segments of society. This objection often involves concerns about the purported harmful effects of market transactions on particular relations, goods, services, or society at large due to an inappropriate valuation and has both a (frequently unacknowledged) empirical component and a moral component.

"The objection is empirical because it contends that markets in certain items and activities change the way in which society and its members perceive those items and activities or the non-market relationships through which they would otherwise be supplied. It is also a moral claim, because it rests on a contention that the change is inevitably negative – that certain modes of valuation and visions of the world are superior to others, or at least unsuitable to certain situations ( Anderson1993).

...

"This Article critiques these empirical claims on two grounds. First, as noted by others, market skeptics fail to provide evidence of the negative effects they hypothesize, despite widespread variation over time and across legal regimes. Second, and more importantly, these objections fail to account for the well-documented human tendency to fashion repugnant exchanges in a manner that reinforces – rather than undermines – deeply held values and relationships. The fact that a particular transaction is deemed morally repugnant by large swathes of society does not, after all, mean that such transactions disappear, even in the face of strong legal sanctions and criminal prohibitions. But it does mean that such exchanges may be managed, obfuscated, or reframed in some way, acknowledging and reinforcing the taboo in the process.

...

"to the extent that some, including Sandel (2012), have explicitly contended that ‘market creep’ has occurred without public awareness or debate, that claim is undermined by the full extent to which participants in and third-party observers of repugnant exchange have, in fact, debated, modified, and managed those exchanges over time."

Renewal: "My donor wanted to give me her kidney — and get home in time for Shabbat"

 When reporter Stewart Ain needed a kidney transplant, he contacted Renewal. He explains the process that led to him being matched to an altruistic donor and transplanted.

My donor wanted to give me her kidney — and get home in time for Shabbat  By Stewart Ain

"Two months later, my wife Meryl and I were sitting in Renewal’s office speaking with Rabbi Josh Sturm, Renewal’s director of outreach, and Miriam Lefkowitz, Renewal’s kidney coordinator. We were told to reach out to friends, relatives, neighbors — everyone we knew — and ask them to listen to an online presentation the rabbi would make about what kidney donation entails and how it literally gives the recipient a new life. 

"As we walked out the door, the rabbi said they had found that if at least 200 people listened to the presentation, the odds were very good a donor would be found. And the donor would not necessarily be someone actually listening online but often from the advance publicity the presentation would generate.

"Renewal created a flier for us with information about the upcoming presentation. At my request, several synagogues posted it on their websites, a couple of Jewish weekly newspapers ran it each week, and Hadassah Magazine featured my story in an article about kidney transplants. One of the three synagogues we belong to contacted the NBC station in West Palm Beach, Florida. The station’s reporter interviewed both me and one the synagogue’s rabbis. A story about my need for a kidney was on the evening newscasts.

"The presentation took place during the 10 days between Rosh Hashanah and Yom Kippur last fall. More than 250 computers tuned in. In the following days I learned that several people had asked Renewal for the nasal-swab kit needed to see if they were a match for me. Later, I heard from several friends and relatives that they had been disqualified as donors for various reasons. "

His donor may not have been one of those who had heard the presentation about his case.

"The idea of donating one of her kidneys surfaced again last Hanukkah when someone mentioned that their daughter had just donated a kidney through Renewal. She contacted the organization in November, and three days later received a swab kit. On Jan. 17, a rabbi from Renewal called and asked if she was still interested in donating. When she said yes, she was told she was a match for two people.

“I remember saying, `I’m not going to play God, let whoever is a better match have it,” she said."

Both patient and donor are doing well.