Friday, July 20, 2018

Proposed new legislation: Organ Donor Clarification Act

Here's an Act that would encourage evidence-based policy towards reducing the dis-incentives to donate a kidney or part of a liver for transplantation.  (Evidence is not so popular these days, and compensation for donors is a red flag, so I expect it may yet meet with opposition, as did a differently composed previous attempt in 2016 .  So far I can't find the current version online--it looks like it will eventually be here-- but the offline version I've seen looks like something I will support:)


Jul 19, 2018 
Press Release

Effort Comes Amidst Shortage, Resulting in Thousands of Preventable Deaths Every Year
Washington, DC – Addressing our nation’s dire organ transplant shortage U.S. Representative Matt Cartwright (D-PA) introduced the Organ Donor Clarification Act on July 19th.There are 115,000 people on the organ transplant waiting list and 20 people die every day as they wait for an organ. This bipartisan legislation will remove existing hurdles for donation and test out new ways to increase donations.
This is life and death; 20 people die every day because they could not survive the wait for a viable organ,” Rep. Cartwright said.  “Kidney waiting lists in major cities can last from five to ten years, which is often longer than a patient can survive on dialysis.
The number of people in the United States with kidney failure has increased by nearly 20% since 2000 and there are currently over 95,000 Americans on the national waitlist for a kidney. Each year 17,000 patients receive a kidney transplant, while about 35,000 new patients are added to the kidney waiting list. As many as 80,000 additional patients may be good candidates for kidney transplant, but have never even been listed. 
This legislation removes existing barriers that donors face under current law and allows for a pilot program to test the effectiveness of non-cash incentives to increase the supply of organs for transplantation.
Currently, organ transplantation is governed by the National Organ Transplant Act (NOTA) of 1984.  This law prohibits buying or selling organs for “valuable consideration.” 
“Confusion about what constitutes valuable consideration hampers donation by scaring people away from reimbursing organ donors for things like medical expenses and lost wages,” said Rep. Cartwright.  “Reimbursements are legal under NOTA, but the law’s lack of clarity and criminal penalties have created uncertainty that has prevented or delayed reimbursements in many cases. Additionally, this bill will allow experts and scientists to run pilot programs – subject to ethical review and government oversight – to test the effect of non-cash incentives in reducing the organ transplant waiting list.”
The expanding kidney wait list has also become a burden on our nation’s finances, as costs for dialysis and other intermediary treatments become more expensive each year. The taxpayer ends up footing the bill through Medicare and other social service programs. Experts project that eliminating the waiting list would save taxpayers well in excess of $5.5 billion per year in medical costs and billions of dollars more in savings to other social programs.
The Organ Donor Clarification Act would:
  • Clarify that certain types of payments are not valuable consideration but are reimbursements for expenses a donor incurs.
  • Allow government-run pilot programs to test the effectiveness of providing non-cash incentives to promote organ donation.  These pilot programs would have to pass ethical board scrutiny, be approved by HHS, distribute organs through the current merit based system, and last no longer than five years.
The Organ Donor Clarification Act has been endorsed by the following organizations:
  • American Medical Association
  • American Liver Foundation
  • Americans for Tax Reform
  • American Foundation for Donation and Transplantation
  • American Transplant Foundation
  • Chris Klug Foundation
  • Donor to Donor
  • Flood Sisters Kidney Foundation
  • Foundation for Kidney Transplant Research
  • Transplant First Academy
  • WaitList Zero

The Bill is cosponsored by the following bipartisan members of the House of Representatives:
Rep. Jason Lewis (R-MN), Rep. Sanford Bishop (D-GA), Rep. André Carson (D-IN), Rep. Steve Cohen (D-TN), Rep. Brian Fitzpatrick (R-PA), Rep. Raul Grijalva (D-AZ),  Rep. Lynn Jenkins (R-KS), Rep. E.B. Johnson (D-TX), Rep. Mike Kelly (R-PA), Rep. Ro Khanna (D-CA), Rep. Tom Marino (R-PA), Rep. Jim McGovern (D-MA), Rep. Jared Polis (D-CO), Rep. Bill Posey (R-FL), Rep. Don Young (R-AK)

Thursday, July 19, 2018

Manipulation by doctors of the Organ Allocation System Waitlist Priority

You will be shocked to learn that doctors and transplant centers respond to incentives in their effort to get scarce organ transplants for their own patients...

Here's a recent OPTN/UNOS white paper on the subject, concerning the waitlist for organs (such as hearts) for which physician decisions can influence patients' position on the waitlist.

Manipulation of the Organ Allocation System Waitlist Priority through the Escalation of Medical Therapies

"This white paper provides an ethical analysis of physicians’ practices of escalating care to waitlisted transplant candidates in order to increase their priority in the allocation system. Many in the transplant community perceive, as expressed explicitly in the medical literature23, that this practice of unnecessary escalation of care is widespread, and recognize that physicians may feel compelled to similarly manipulate the waitlist priority system so that their candidates are not disadvantaged as a result of the practices of others.

"For example, in heart transplantation, priority status can be influenced by the degree of therapeutic intervention applied to the transplant candidate, based on the assumption that therapeutic measures are a reliable indicator of disease severity.4 An unintended consequence of this approach is that a physician can raise the priority status of a patient by instituting more advanced therapeutic measures even in the absence of true medical necessity, a tactic some informally refer to as “gaming.”

"Due to the organ shortage, the transplant waitlist “is functionally a zero-sum rationing process.”5 Shortening wait times for some directly increases wait times for others. Thus, the practice of instituting more advanced therapies to shorten an individual’s wait time has no beneficial effect on wait times for the patient population in the aggregate. However, manipulating care to achieve a higher candidate priority can generate complications in candidates receiving such care while also jeopardizing public trust in the organ allocation system, which in turn, could reduce organ donation rates.

"OPTN/UNOS leadership requested an ethical analysis regarding the manipulation of the organ allocation system, particularly as it pertains to medically unnecessary escalation of interventions that are instituted for the sole purpose of increasing a candidate’s waitlist priority. The OPTNhas not previously commented on this issue."

"During the mid-late 1990s, three transplant hospitals in Chicago, IL were alleged by federal and state authorities to have falsely reported patients as critically ill in order to house them in the intensive care unit for the purpose of moving them to the top of the liver transplant waitlist.20 The hospitals denied any wrongdoing, but did receive financial penalties. These incidents generated questions about the integrity and fairness of the liver allocation system based on the alleged events.21,22

"In the last five years, prominent editorials described the widespread use of medical interventions that are not thought to be medically indicated in routine practice, but allow for patients to receive higher waitlist priority.23,24 This includes increased utilization of pulmonary artery (PA) catheters with continuous inotropes for the purpose of increasing the priority status on the waitlist of a patient with heart failure.25 While there are situations in which PA catheter use is appropriate, this intervention is associated with excessive adverse complications, which typically prohibits its routine use. When use of PA catheters was aligned with allocation priority, increasing use of PA catheters quickly followed.26 Further, vascular complications that preclude further catheterization have evolved to become a major justification for Status 1A exceptions, which are presumed to be related to overuse of PA catheters.27,28

"Increasingly, heart transplant candidates are being listed as Status 1A (the highest priority), which is largely based on the intensity and risk of the intervention used to treat the patient. This category was originally intended for potential transplant candidates expected to survive less than one week. Now, it’s not uncommon for Status 1A patients to have longer waitlist survival, and they may wait 6-12 months ."
"Multiple stakeholders stand to gain from manipulating the allocation system, including the candidate and the transplant hospital."

Wednesday, July 18, 2018

Matching endorsements to endorsers

The NY Times reports on speed dating of Youtube influencers and brands (and on newly relevant "moral turpitude" clauses concerning both parties):

Inside the Mating Rituals of Brands and Online Stars
By Daisuke Wakabayashi

"Recently at the Anaheim Convention Center, about 50 people entered a room decorated as a stylish lounge for a speed dating event. They moved from table to table every 20 minutes, exchanging small talk and getting to know each other.
But the participants were not looking for love. They were YouTube stars and marketing executives from companies like Uber and Amazon seeking an advertising union.

"Deals between big brands and viral online video performers, once an informal alternative to traditional celebrity sponsorships, are quickly maturing into a business estimated to reach $10 billion in 2020.
"As the attention and money paid to stars on sites like YouTube and Instagram balloon, the stakes for both them and the brands to find the right match are rising. The speed dating event, held during VidCon, the online video industry’s annual convention, was one way the two sides are testing each other out.
"Most advertising deals with YouTube or Instagram stars now include a “morality clause.” One such agreement, shown to The New York Times, stated that a creator would agree to take down any content within 12 hours if the brand determined that the talent had promoted a competing product, posted “racy content” on social media or performed “an act of moral turpitude.”
Increasingly, [an agent] wants the same right for his clients because they have just as much to lose if a company becomes embroiled in scandal, such as the right to take down a video sponsored by a company if that brand’s executives are caught sexually harassing staff."

Update: and here's a recent paper on the subject:

The Market for Influence
39 Pages Posted:  

Itay P Fainmesser

Johns Hopkins University - Carey Business School

Andrea Galeotti

University of Essex
Date Written: July 3, 2018


Influencer marketing is the fast growing practice in which marketers purchase product endorsements from influencers, who are individuals with many followers and strong reputations in niche markets. This paper develops a model of the market interactions between influencers, followers and marketers. Influencers trade-off the increased revenue they obtain by posting more paid endorsements, with the negative impact that this has on their followers’ engagement, which in turn affects the price marketers are willing to pay for their endorsement. Our analysis provides testable predictions on how the price that influencers receive depends on the size of their audience, and how an improvement in the online search technology affects influencers’ competition for followers and marketers. We show that, in equilibrium, over- and under-provision of paid endorsements coexist. We evaluate the strategic effects of recent, trans- parency motivated, policy interventions implemented by competition authorities in the US and Europe, requiring influencers to clearly mark the content that is sponsored by marketers.

Tuesday, July 17, 2018

Compensation for plasma donors--calls for a ban in Canada

At the same time as there are calls for decriminalizing drug use in Canada (see yesterday's post), there are calls for bans on compensating plasma donors. (Repugnance is a big topic..)

This post collects some thoughts on compensation for plasma donors, following my participation in the recent Plasma Protein Forum.

Much discussed there is the rash of recent legislation and proposed legislation in Canada to ban compensation for donors (a sort of repugnance event...).

B.C. joins 3 other provinces in banning payment for blood and plasma
Alberta, Ontario and Quebec already have laws prohibiting profit from blood donations

Senator introducing bill to ban payments for blood donation
"“The point of this bill is better safe than sorry,” Wallin said.

“Canadian blood donors are not meant to be a revenue stream.”


One perplexing feature of this debate is that Canada already buys lots of plasma from the U.S., where it is supplied by paid donors. No one seems to be suggesting that should be changed.

(Here are my posts to date on plasma in Canada.)
In related notes, China seems to be ramping up it's "source" plasma collection (obtained at the source via plasmapheresis, as distinct from "recovered" plasma obtained from whole blood donations), with collection of about 7 million liters in 2017.  My understanding is that Chinese law forbids the importation of blood products except for albumin.

See this Lancet editorial from 2017:
"China,  a  country  that  holds  the  questionable  honour  of  being a world leader in liver disease, is now also the highest consumer  of  serum  albumin,  using  300  tonnes  annually,  roughly  half  of  the  worldwide  total  use,  according  to  an  article  in  the  Financial  Times. 

In Brazil, compensation of plasma donors is forbidden (along with compensation of organ donors) in the Constitution, article 199
"(4) The law establishes the conditions and requirements to allow the removal of human organs, tissues, and substances intended for transplantation, research, and treatment, as well as the collection, processing, and transfusion of blood and its by products, all kinds of sale being forbidden."

Monday, July 16, 2018

New calls for decriminalizing drug use in Canada

Here's the story in the Washington Post:

Toronto medical official calls for decriminalizing drugs as opioid overdoses skyrocket in Canada

"With opioid-related overdoses and deaths reaching record levels in Canada, the top medical official in Toronto is calling for the decriminalization of all drugs as part of a strategy to treat illicit drug use as a public health and social issue, not a criminal one.

"In a report released Monday, Eileen de Villa, Toronto’s chief medical officer, urged the city’s board of health to pressure the federal government to eliminate legal penalties for the possession of drugs and to scale up “prevention, harm reduction and treatment services.”

"The report also recommended assembling a task force “to explore options for the legal regulation of all drugs in Canada,” which she hopes would destroy an illegal drug market contaminated with fentanyl — a synthetic opioid 100 times more potent than morphine — and other drugs like it.

“When we criminalize people who take drugs, we inadvertently contribute to the overdose emergency,” de Villa said. “It pushes people into unsafe drug use practices and creates barriers for people to seek help.”

Here's the Toronto report:
A Public Health Approach to Drug Policy
Date: June 28, 2018
To: Board of Health
From: Medical Officer of Health

See also the Global Commission on Drug Policy's 2016 report:

Sunday, July 15, 2018

Kidney exchange is fragmented in the U.S.

Market Failure in Kidney Exchange

Nikhil AgarwalItai AshlagiEduardo AzevedoClayton R. FeatherstoneÖmer Karaduman

NBER Working Paper No. 24775
Issued in June 2018

Abstract: "We show that kidney exchange markets suffer from traditional market failures that can be fixed to increase transplants by 25%-55%. First, we document that the market is fragmented and inefficient: most transplants are arranged by hospitals instead of national platforms. Second, we propose a model to show two sources of inefficiency: hospitals do not internalize their patients’ benefits from exchange, and current mechanisms sub-optimally reward hospitals for submitting patients and donors. Third, we estimate a production function and show that individual hospitals operate below efficient scale. Eliminating this inefficiency requires a combined approach using new mechanisms and solving agency problems."

Here's a key sentence:
"The three largest multi-hospital platforms together only account for a minority share of the kidney exchange market. 62% of kidney exchange transplants are within hospital transplants that are not facilitated by the NKR, APD or UNOS. Moreover, over 100 hospitals performed kidney exchanges outside these three platforms during this period."

Saturday, July 14, 2018

Jason Furman buys books when they're on sale

Here's a recent book review of my (2015) book that caught my eye, posted by Ismail Ali Manik, which begins with this tweet:
 Random Book recommendation — Who Gets What and Why: The New Economics of Matchmaking and Market Design

You might want to read the book yourself, and in any event there is an interesting selection of quotes, and then links to a bunch of videos, at the link above.