Stanford graduation--Alex Chan, Ph.D.

 Congratulations Dr. Chan.

Welcome to the club, Alex.

Alex Chan makes his 'final presentation' at Stanford.

 

Note Alex's shoes

Alex Chan

 Congratulations, Alex.

Alex Chan

@alex8chan

·

Mar 24

I will join

@HarvardHBS

as an Assistant Professor next academic year! to the sacrifices my family made for me + their support… #HBS #FirstGen + my advisors who made this dream possible #AlRoth

@MurielNiederle

@LaurenceCBaker

@MichelleM_Mello

@I_am_NickBloom

@SIEPR

@Stanford

And earlier (in October)

Welcome to the club, Alex.

Three way liver exchange in Pakistan, reported in JAMA Surgery by Salman, Arsalan, and Dar, in collaboration with economist Alex Chan

 Here's an exciting account, just published in JAMA Surgery, of a three way liver exchange in Pakistan, achieved in part by collaboration with economist and market designer Alex Chan (who is on the job market this year).

Launching Liver Exchange and the First 3-Way Liver Paired Donation by Saad Salman, MD, MPH1; Muhammad Arsalan, MBBS2; Faisal Saud Dar, MBBS2, JAMA Surg. Published online December 7, 2022. doi:10.1001/jamasurg.2022.5440 (pdf)

Here are the first paragraphs:

"There is a shortage of transplantable organs almost everywhere in the world. In the US, about 6000 transplant candidates die waiting each year.1 In Pakistan, 30% to 50% of patients who needed a liver transplant are unable to secure a compatible donor, and about 10 000 people die each year waiting for a liver.2 Kidney paired donations, supported by Nobel Prize–winning kidney exchange (KE) algorithms,3 have enabled living donor kidneys to become an important source of kidneys. Exchanges supported by algorithms that systematically identify the optimal set of paired donations has yet to take hold for liver transplant.

"The innovation reported here is the successful implementation of a liver exchange mechanism4 that also led to 3 liver allotransplants and 3 hepatectomies between 3 incompatible patient-donor pairs with living donor–patient ABO/size incompatibilities. These were facilitated by one of the world’s first documented 3-way liver paired donations (LPD) between patient-donor pairs.

"Since 2018 and 2019, we have explored LPD as a strategy to overcome barriers for liver failure patients in Pakistan in collaboration with economist Alex Chan, MPH.2 With LPD, the incompatibility issues with relative donors can be solved by exchanging donors. The Pakistan Kidney and Liver Institute (PKLI) adopted a liver exchange algorithm developed by Chan4 to evaluate LPD opportunities that prioritizes clinical urgency (Model for End-stage Liver Disease [MELD] scores) while maximizing transplant-enabling 2-way or 3-way swaps that ensures that hepatectomies for every donor within each swap has comparable ex ante risk (to ensure fairness). As of March 2022, 20 PKLI liver transplant candidates had actively coregistered living and related but incompatible liver donors. Evaluating these 20 incompatible patient-donor pairs with the algorithm,4 we found 7 potential transplants by two 2-way swaps and the 3-way swap reported. In contrast to ad hoc manual identification of organ exchange opportunities, the hallmark of a scalable organ exchange program is the regular deployment of algorithms to systematically identify possible exchanges. Regular deployment of LPD algorithms is novel.

"A total of 6 procedures took place on March 17, 2022. Patient 1, a 57-year-old man, received a right liver lobe from donor 2, a 28-year-old coregistered donor of patient 2 (56-year-old man), who in turn received a right liver lobe from donor 3, a 35-year-old woman who was a coregistered donor of patient 3. Patient 3, a 46-year-old man, received a right liver lobe from donor 1, a 22-year-old woman who was a coregistered donor of patient 1, completing the cycle (Figure). Five PKLI consultant surgeons and 7 senior registrars led the hepatectomies and liver allotransplants; 6 operating rooms were used simultaneously. One month postsurgery, all patients and donors are robust with no graft rejection. All the donors are doing well in the follow-up visits and have shown no psychological issues."

Here's a sentence in the acknowledgements:

"We thank Alex Chan, MPH (Stanford University, Palo Alto, California), whose initiative and expertise in economics were the key driving forces for launching liver exchange."

*********

NB: this is a "Surgical Innovation" article, for which the journal requires that there be no more than three authors.

And here are the references cited:

1.

Chan  A, Roth  AE. Regulation of organ transplantation and procurement: a market design lab experiment. Accessed April 28, 2022. https://www.alexchan.net/_files/ugd/a47645_99b1d4843f2f42beb95b94e43547083b.pdf

2.

Salman  S, Gurev  S, Arsalan  M, Dar  F, Chan  A. Liver exchange: a pathway to increase access to transplantation. Accessed April 1, 2022. http://www.hhpronline.org/articles/2021/1/14/liver-exchange-a-pathway-to-increase-access-to-transplantation

3.

Henderson  D. On marriage, kidneys and the Economics Nobel. Wall Street Journal. October 15, 2012. Accessed March 5, 2022. https://www.wsj.com/articles/SB10000872396390443675404578058773182478536

4.

Chan  A. Optimal liver exchange with equipoise. Accessed April 23, 2022. https://www.alexchan.net/_files/ugd/a47645_36e252f4df0c4707b6431b0559b03143.pdf

5.

Hwang  S, Lee  SG, Moon  DB,  et al.  Exchange living donor liver transplantation to overcome ABO incompatibility in adult patients.   Liver Transpl. 2010;16(4):482-490. doi:10.1002/lt.22017PubMedGoogle ScholarCrossref

6.

Patel  MS, Mohamed  Z, Ghanekar  A,  et al.  Living donor liver paired exchange: a North American first.   Am J Transplant. 2021;21(1):400-404. doi:10.1111/ajt.16137PubMedGoogle ScholarCrossref

7.

Braun  HJ, Torres  AM, Louie  F,  et al.  Expanding living donor liver transplantation: report of first US living donor liver transplant chain.   Am J Transplant. 2021;21(4):1633-1636. doi:10.1111/ajt.16396

 ********

Here's a Stanford story on this collaboration:

Stanford student devises liver exchange, easing shortage of organs. A rare three-way exchange of liver transplants in Pakistan was made possible with a new algorithm developed by a Stanford Medicine student.  by Nina Bai

"The liver exchange idea actually came out of a term paper in a first-year market design class at Stanford," Chan said.

"As he learned more about liver transplants, Chan realized there were important biological and ethical differences from kidney transplants. 

...

"Instead of just finding compatible swaps, we want to find swaps that prioitize the most urgent patients first in order to prevent the most deaths," Chan said.

*******

Here are some contemporaneous stories from March in the newspaper Dawn (now that the JAMA embargo on the story is lifted):

Liver transplants at PKLI under 'swap' plan - Newspaper - Dawn

Mar 18, 2022 — A highly-trained team of the surgeons headed by PKLI Dean Prof Faisal Dar had performed liver transplants at the institute and other members ...

• First swap liver transplant surgeries at PKLI today - Dawn

  
  

  Mar 17, 2022 — An official told Dawn on Wednesday the treating doctors had recommended liver transplant of all the three patients due to their end-stage ...

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.

Rising Stars in Market Design, featuring Alex Chan, Aram Grigoryan and Dong Woo Hahm, at the Tokyo Market Design center

 The University of Tokyo Market Design center hosts Rising Stars in Market Design

Alex Chan, Aram Grigoryan, Dong Woo Hahm

Market design course for health policy and medical students, at Stanford, taught by Alex Chan and Kurt Sweat

 Starting tomorrow, a short course in market design:

BIOS 203, Fall 2021: Market Design and Field Experiments for Health Policy and Medicine 

Primary Instructor: Alex Chan chanalex@stanford.edu | Office Hours: By appointment

Secondary Instructor: Kurt Sweat kurtsw@stanford.edu | Office Hours: By appointment

Description. Market design is an emerging field in economics, engineering and computer science about how to organize systems to allocate scarce resources. In this course, we study (1) the theory and practice of market design in healthcare and medicine, and (2) methods to evaluate the impact of such designs. Students will be provided with the necessary tools to diagnose the problems in markets and allocation mechanisms that render them inefficient, and subsequently develop a working toolbox to remedy failed markets and finetune new market and policy designs.

With a practical orientation in mind, we will learn how to construct rules for allocating resources or to structure successful marketplaces through successive examples in healthcare and medicine: medical residency matching, kidney exchange, allocation of scarce medical resources like COVID vaccine and tests, medical equipment procurement, online marketplace for doctors, and, if time permits, reward system for biopharmaceutical innovation. Guest lectures by practicing market designers and C-suite healthcare executives (CEO, CFO) would feature in the course as well.

An important goal of the class is to introduce you to the critical ingredients to a successful design: a solid understanding of institutions, grasps of economic theory, and well-designed experiments and implementation. In the final sessions, students will also learn how to design and deploy one of the most powerful tools in practical market design: A/B testing or randomized field experiments. These techniques are widely used by tech companies like UBER, Amazon, eBay, and others to improve their marketplaces.

At the end of the course, students should have acquired the necessary knowledge to become an avid consumer and user, and potentially a producer, of the market design and field experimental literature (recognized by 4 recent Nobel Prizes in Economics: 2007/2012/2019/2020).

Time & Location.

● Tue, Thu 6:30 PM - 8:00 PM (beginning November 16, 2021) at Encina Commons Room 119

Course Webpage. ● https://canvas.stanford.edu/courses/145148

Schedule and Readings

(* required readings, others are optional)

Session 1. Market design and Marketplaces – November 16

1. * Roth, A. E. (2007). The art of designing markets. harvard business review, 85(10), 118.

2. Kominers, S. D., Teytelboym, A., & Crawford, V. P. (2017). An invitation to market design. Oxford Review of Economic Policy, 33(4), 541-571.

3. Roth, A. E. (2002). The economist as engineer: Game theory, experimentation, and computation as tools for design economics. Econometrica, 70(4), 1341-1378

Session 2. Matching Markets: Medical Residents and the NRMP – November 18

1. * Chapter 1 in Gura, E. Y., & Maschler, M. (2008). Insights into game theory: an alternative mathematical experience. Cambridge University Press.

2. * Fisher, C. E. (2009). Manipulation and the Match. JAMA, 302(12), 1266-1267.

3. * National Resident Matching Program. (2021). Feasibility of an Early Match NRMP Position Statement

4. Roth, A. E., & Peranson, E. (1997). The effects of the change in the NRMP matching algorithm. JAMA, 278(9), 729-732.

5. Gale, D., & Shapley, L. S. (1962). College admissions and the stability of marriage. The American Mathematical Monthly, 69(1), 9-15.

Session 3. Kidney Exchange and Organ Allocation – November 30

1. * Wallis, C. B., Samy, K. P., Roth, A. E., & Rees, M. A. (2011). Kidney paired donation. Nephrology Dialysis Transplantation, 26(7), 2091-2099.

2. * Chapter 3 in Roth, A. E. (2015). Who gets what—and why: The new economics of matchmaking and market design. Houghton Mifflin Harcourt.

3. Gentry, S. E., Montgomery, R. A., & Segev, D. L. (2011). Kidney paired donation: fundamentals, limitations, and expansions. American journal of kidney diseases, 57(1), 144-151.

4. Salman, S., Gurev, S., Arsalan, M., Dar, F., & Chan, A. Liver  Exchange: A Pathway to Increase Access to Transplantation.

5. Sweat, K. R. Redesigning waitlists with manipulable priority: improving the heart transplant waitlist.

6. Agarwal, N., Ashlagi, I., Somaini, P., & Waldinger, D. (2018). Dynamic incentives in waitlist mechanisms. AEA Papers & Proceedings, 108, 341-347.

Session 4. 1 st Half: Repugnance as a Constraint on Markets – December 2

1. * Roth, A. E. (2007). Repugnance as a Constraint on Markets. Journal of Economic perspectives, 21(3), 37-58.

2. * Minerva, F., Savulescu, J., & Singer, P. (2019). The ethics of the Global Kidney Exchange programme. The Lancet, 394(10210), 1775-1778.

3. Chapter 11 in Roth, A. E. (2015). Who gets what—and why: The new economics of matchmaking and market design. Houghton Mifflin Harcourt.

2 nd Half: Market Design and Allocation during COVID-19 – December 2

1. * Emanuel, E. J., Persad, G., Upshur, R., Thome, B., Parker, M., Glickman, A., ... & Phillips, J. P. (2020). New England Journal of Medicine. Fair allocation of scarce medical resources in the time of Covid-19.

2. Piscitello, G. M., Kapania, E. M., Miller, W. D., Rojas, J. C., Siegler, M., & Parker, W. F. (2020). Variation in ventilator allocation guidelines by US state during the coronavirus disease 2019 pandemic: a systematic review. JAMA network open, 3(6), e201

3. Schmidt, H., Pathak, P., Sönmez, T., & Ünver, M. U. (2020). Covid-19: how to prioritize worse-off populations in allocating safe and effective vaccines. British Medical Journal, 371.

4. Schmidt, H., Pathak, P. A., Williams, M. A., Sonmez, T., Ünver, M. U., & Gostin, L. O. (2020). Rationing safe and effective COVID-19 vaccines: allocating to states proportionate to population may undermine commitments to mitigating health disparities. Ava

5. Neimark, J. (2020). What is the best strategy to deploy a COVID-19 vaccine. Smithsonian Magazine.

Session 5. 1 st Half: Auction Design and Procurement in Medicine – December 7

1. * The Committee for the Prize in Economic Sciences in Memory of Alfred Nobel. (2020). Improvements to auction theory and inventions of new auction formats. Scientific Background on the Sveriges Riksbank Prize in Economic Sciences in Memory of Alfred Nobel 20

2. * Song, Z., Cutler, D. M., & Chernew, M. E. (2012). Potential consequences of reforming Medicare into a competitive bidding system. Jama, 308(5), 459-460.

3. Newman, D., Barrette, E., & McGraves-Lloyd, K. (2017). Medicare competitive bidding program realized price savings for durable medical equipment purchases. Health Affairs, 36(8), 1367-1375.

4. Cramton, P., Ellermeyer, S., & Katzman, B. (2015). Designed to fail: The Medicare auction for durable medical equipment. Economic Inquiry, 53(1), 469-485.

5. Ji, Y. (2019). The Impact of Competitive Bidding in Health Care: The Case of Medicare Durable Medical Equipment.

6. Thaler, R. H. (1988). Anomalies: The winner's curse. Journal of economic perspectives, 2(1), 191-202.

7. Chapter 2 in Haeringer, G. (2018). Market design: auctions and matching. MIT Press.

2 nd Half: (GUEST LECTURE) Ralph Weber, CEO, MediBid Inc. on “The Online Marketplace for Medicine” – December 7

Session 6. A/B Testing and Field Experiments to Test Designs – December 9

1. * Chapters 1, 4 in List, John. (2021). A Course in Experimental Economics (unpublished textbook, access on course website)

2. * Gallo, A. (2017). A refresher on A/B testing. Harvard Business Review, 2-6.

3. Chan, A. (2021). Customer Discrimination and Quality Signals – A Field Experiment with Healthcare Shoppers.

4. Kessler, J. B., Low, C., & Sullivan, C. D. (2019). Incentivized resume rating: Eliciting employer preferences without deception. American Economic Review, 109(11), 3713-44.

5. Chapters 3, 5, 6, 7, 8 in List, John. (2021). A Course in Experimental Economics (unpublished textbook, access on course website)

6. The Committee for the Prize in Economic Sciences in Memory of Alfred Nobel. (2019). Understanding development and poverty alleviation. Scientific Background on the Sveriges Riksbank Prize in Economic Sciences in Memory of Alfred Nobel 2019.

Bonus Session (optional). (GUEST LECTURE) Donald Lung, CFO, Antengene on “Designing Markets to Access Biopharmaceutical Intellectual Property Across Regulatory Regimes – the Case of China” – Date TBD

Bonus Session (optional). (GUEST LECTURE) TBD – Date TBD

Intermediation in the wholesale pharmaceutical market, by Alex Chan and Kevin Schulman

Intermediaries called Pharmacy benefit managers (PBMs) play an important, but complicated role in the market for pharmaceutical drugs. Here's an article by Chan and Schulman, explaining why the role of PBM's is so opaque (quick summary: the industry is very concentrated, and is paid by both sides of the transactions that are being intermediated...)

Examining Pharmaceutical Benefits in the United States
Alex Chan,  Kevin Schulman

"...consolidation has resulted in a situation in which the 3 largest PBMs have approximately 80% market share.
...
"One of the largest criticisms of PBMs is the lack of transparency surrounding the structure and scale of payments from manufacturers to the PBM. The current PBM business model is shrouded in secrecy. Descriptions of PBM audits by payers and employers entail visits to PBM sites and examination of paper records under conditions of confidentiality, usually performed by a set of consultants that specialize in this role.5 Only the PBM knows the actual scope of payments from drug manufacturers to the PBM (for example, rebates and other payments, such as service fees). In 2016, for 13 pharmaceutical companies, payments to PBMs and other intermediaries were $100 billion, or 50% of gross sales.2 Without transparency, a PBM might develop formularies that maximize payments to the PBM rather than maximize value to patients. Anthem sued its PBM for $15 billion in 2016 for overpayments on drug pricing.6

"Finally, the issue of who is negotiating on whose behalf in drug markets remains contentious. In other words, the agency of PBMs is not clear. When PBMs depended on service fees from health plans and employers as their main source of revenue, it was clear that they served the payer (ie, the employer or the health plan). Under the rebate model, the role of the PBM has evolved to serving as an agent of both the payer and the manufacturer. In fact, as the prescription drug market has evolved, PBM profits appear to have grown with the growth of rebate dollars and manufacturer payments rather than with the growth of payer fees. It is increasingly hard to disentangle the multiple roles of the PBM and to clarify who PBMs serve as intermediaries."

Alex Chan on deceased organ donation policy, in JAMA

Alex Chan comments on an earlier article in JAMA:
US Organ Donation Policy
Alex Chan, January 21, 2020

"To the Editor Ms Glazier and Mr Mone touted the success of the current opt-in organ donation system and argued for focusing on increasing registered donors to 75% of the adult population.1 A challenge is the intrinsic difficulty of such a task: more coordinated promotional efforts and new incentives like giving registered donors priority on organ waiting lists would likely be required.

"Even if such an increase in donor registration is possible, another challenge is the extent to which transplant centers recover organs from registered donors. Although the number of registered donors is more than half of the US population, only 36.3% of possible donors become actual donors.2 This loss of approximately one-third of registered donors suggests that obstacles to recovery of organs, such as family objection, transplant center rejections of imperfect organs, and OPO performance, are pivotal. Anecdotal evidence suggests that rejections of imperfect organs account for approximately 10% to 20%,2 leaving 10% to 20% of the loss still unaccounted for. Family consent or its lack may be a big part of the gap.
...
"Furthermore, 2 of the 3 states with the highest donor registration rates (Montana, 93%; Washington, 89%) have lower-than-average actual donation rates,1,2 but states like Nevada and Pennsylvania with registration rates lower than 50% have actual donation rates much higher than the national average.2 This suggests that registration is only part of the solution, and the ability of OPOs to obtain family consent and convert registrations into donations can bound the effectiveness of the current system."

*********
Here's the earlier post, about the article on which Alex is commenting

Wednesday, August 14, 2019

How is the U.S. opt in system of organ donation doing compared to an opt out system? Alex Glazier and Tom Mone in JAMA