New rules for evaluating transplant centers

 Historically, transplant centers ('hospitals') have been primarily evaluated on the one year graft survival on the transplants that they do.*  Now Medicare announces it will test a new model, that will emphasize the number of transplants conducted ("achievement"), in addition to somewhat less emphasis on the ratio of deceased donor kidneys accepted or rejected ("efficiency") and graft survival ("quality").

Medicare Program; Alternative Payment Model Updates and the Increasing Organ Transplant Access (IOTA) Model.  A Rule by the Centers for Medicare & Medicaid Services on 12/04/2024 

"a. Proposed IOTA Model Overview

"End-Stage Renal Disease (ESRD) is a medical condition in which a person's kidneys cease functioning on a permanent basis, leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life.[2]

"The best treatment for most patients with kidney failure is kidney transplantation. Nearly 808,000 people in the United States are living with ESRD, with about 69 percent on dialysis and 31 percent with a kidney transplant.[3]

"Relative to dialysis, a kidney transplant can improve survival, reduce avoidable health care utilization and hospital acquired conditions, improve quality of life, and lower Medicare expenditures.[4 5]

"However, despite these benefits of kidney transplantation, evidence shows low rates of ESRD patients placed on kidney transplant hospitals' waitlists, a decline in living donors over the past 20 years, and underutilization of available donor kidneys, coupled with increasing rates of donor kidney discards, and wide variation in kidney offer acceptance rates and donor kidney discards by region and across kidney transplant hospitals.[6 7] 

...

"The IOTA Model will be a mandatory model that will begin on July 1, 2025, and end on June 30, 2031, resulting in a 6-year model performance period comprised of 6 individual performance years (“PYs”). The IOTA Model will test whether performance-based incentives paid to, or owed by, participating kidney transplant hospitals can increase access to kidney transplants for patients with ESRD, while preserving or enhancing quality of care and reducing Medicare expenditures. CMS will select kidney transplant hospitals to participate in the IOTA Model through the methodology proposed in section III.C.3.d of this final rule. As this will be a mandatory model, the selected kidney transplant hospitals will be required to participate. CMS will measure and assess the participating kidney transplant hospitals' performance during each PY across three performance domains: achievement, efficiency, and quality.

"The achievement domain will assess each participating kidney transplant hospital on the overall number of kidney transplants performed during a PY, relative to a participant-specific target. The efficiency domain will assess the kidney organ offer acceptance rate ratios of each participating kidney transplant hospital relative to a national ranking or the participating kidney transplant hospital's past organ offer acceptance rate ratio. The quality domain will assess the quality of care provided by the participating kidney transplant hospitals via a composite graft survival ratio. Each participating kidney transplant hospital's performance score across these three domains will determine its final performance score and corresponding amount for the upside risk payment that CMS would pay to the participating kidney transplant hospital, or the downside risk payment that would be owed by the participating kidney transplant hospital to CMS. The upside risk payment will be a lump sum payment paid by CMS after the end of a PY to a participating kidney transplant hospital with a final performance score of 60 or greater. Conversely, beginning in PY 2, the downside risk payment will be a lump sum payment paid to CMS by any participating kidney transplant hospital with a final performance score of 40 or lower. There is no downside risk payment for PY 1 of the model.

...

"The three performance domains will include: (1) an achievement domain worth up to 60 points, (2) an efficiency domain worth up to 20 points, and (3) a quality domain worth up to 20 points.

"The achievement domain will assess the number of kidney transplants performed by each IOTA participant for attributed patients, with performance on this domain worth up to 60 points. The final performance score will be heavily weighted on the achievement domain to align with the IOTA Model's goal to increase access to kidney transplants to improve the quality of care and reduce Medicare expenditures. The IOTA Model theorizes that improvement activities, including those aimed at reducing unnecessary deceased donor discards and increasing living donors, may help increase access to kidney transplants."

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CMS gives a high level overview here: Increasing Organ Transplant Access (IOTA) Model

and later today there's a webinar you can register for:

"The CMS Innovation Center will be hosting a welcome webinar to present an overview of the model on December 18, 2024, from 2 to 3 p.m. ET. Register to attend: https://cms.zoomgov.com/webinar/register/WN_hvGDyZTxQ5eNhX1OBolevA
 

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*see Wednesday, October 2, 2024 Regulation of Organ Transplantation and Procurement (Chan and Roth in the JPE)

That paper suggests desirable regulations  would coordinate transplant and OPO incentives, and link them both to the health outcomes of all patients attributable to a given transplant center (and not just those patients who were transplanted). 

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quick update (from the Q&A following the webinar): 

this is viewed as an experiment on roughly half the transplant centers, but there isn't currently a commitment about what to do after the projected 6 years of the experiment.

. all transplant patients are considered, but payments are only for Medicare fee for service patients

achievement: . each center's target for annual transplants will be it's average number over the three years ending a year before the beginning of the experiment...(at least that was the answer for the first year).

    . both deceased and living donor outcomes will be included in the achievement metric.

quality: .the first year will consider one-year graft survival, and year n will consider graft survival for the first n years.

OPOs: there are no requirements for OPOs within the IOTA model 

risk adjustment: not for year 1, they are hoping to have risk adjustment measures in subsequent years.

. 

Guns and public health: research funds available again

 Here's the story, from the Journal of the American Medical Association:

Gun Violence Researchers Are Making Up for 20 Years of Lost Time by Alicia Ault, JAMA. Published online August 4, 2021. doi:10.1001/jama.2021.11469

"By late July, the Gun Violence Archive reported 25 370 US firearm deaths in 2021, putting the year on track to surpass last year’s 43 559 deaths. US Centers for Disease Control and Prevention (CDC) data showed that 39 707 people lost their lives to gun violence in 2019. It was the third consecutive year in which US gun violence deaths approached 40 000 and the end of a decade in which the death rate from gun violence increased by 17%, from 10.1 to 11.9 deaths per 100 000 population. The rate has remained above 11 per 100 000 population since 2015.

"Although the CDC gathers firearm mortality data, its gun violence research had largely been dormant since 1996 when the Dickey Amendment prohibited the agency from using its injury prevention funding “to advocate or promote gun control.” The amendment technically didn’t prohibit gun violence research, but the chill was numbing.

"In 2019, however, Congress authorized $25 million in spending on gun violence research, to be split evenly between the CDC and the National Institutes of Health (NIH). Although the amount is nearly 10 times greater than the $2.6 million that the CDC was spending on gun violence prevention studies when the Dickey Amendment took effect, a leading expert said the field is still woefully underfunded.

‘Harm Reduction’ Gains Federal Support.

 Another shot has been fired in the American war against drugs, this time in the battle between those who insist that drug abuse is everywhere and always a criminal problem, and those who think that even drug abusers might be entitled so some support in their personal fight against fatal overdosing.

The NY Times has the story.

Helping Drug Users Survive, Not Abstain: ‘Harm Reduction’ Gains Federal Support. By Abby Goodnough.

"Overdoses have surged during the pandemic. Now, for the first time, Congress has appropriated funds specifically for programs that distribute clean syringes and other supplies meant to protect users."

...

"Overdose deaths rose by nearly 30 percent over the 12-month period that ended in November, to more than 90,000, according to preliminary federal data released this month — suggesting 2020 blew past recent records for such deaths. The staggering increase during the pandemic has many contributing factors, including widespread job loss and eviction; diminished access to addiction treatment and medical care; and an illegal drug supply that became even more dangerous after the country essentially shut down.

...

"Now, with the nation reopening, the Biden administration is throwing support behind the contentious approach ... known as harm reduction. Instead of helping drug users achieve abstinence, the chief goal is to reduce their risk of dying or acquiring infectious diseases like H.I.V. by giving them sterile equipment, tools to check their drugs for fentanyl and other lethal substances, or even just a safe space to nap.

"Such programs have long come under attack for enabling drug use, but President Biden has made expanding harm-reduction efforts one of his drug policy priorities — the first president to do so. The American Rescue Act includes $30 million specifically for evidence-based harm reduction services, the first time Congress has appropriated funds specifically for that purpose. The funding, while modest, is a victory for the programs, both symbolically and practically, as they often run on shoestring budgets.

...

"Still, many elected officials and communities continue to resist equipping people with supplies for drug use, including the recent addition of test strips to check drugs for the presence of illicitly manufactured fentanyl, which shows up in most overdose deaths. Some also say that syringes from harm reduction programs end up littering neighborhoods or that the programs cause an increase in crime. Researchers dispute both claims.

"West Virginia just passed a law making it far more difficult for syringe service programs to operate, even though it is seeing a surge in H.I.V. cases driven by intravenous drug use. North Carolina’s legislature weighed a similar proposal this spring, and elected officials in Scott County, Ind., whose syringe exchange helped curb a major H.I.V. outbreak six years ago, voted this month to shut it down. Mike Jones, a commissioner there who voted to end the program, said at the time that he feared the syringes it distributed could be contributing to overdose deaths."

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Earlier post: 

Friday, May 14, 2021

Clean needle exchange faces renewed opposition in Indiana and elsewhere

NSF is looking for a new Division Director, Social and Economic Sciences, SBE

This is an important job in government science:

Division Director, Social and Economic Sciences, SBE

Responsibilities
Serves as a member of the SBE Directorate leadership team and as a principal spokesperson in social and economic sciences for the Foundation.  Provides leadership and direction to the NSF Division responsible for funding research and education activities, both nationally and internationally, to develop and advance scientific knowledge and methods focusing on our understanding of individuals, social and organizational behavior by creating and sustaining social science infrastructure, and by supporting disciplinary and interdisciplinary research that advances knowledge in the social and economic sciences.  The incumbent has managerial and oversight responsibilities for the effective use of division staff and resources in meeting organizational goals and objectives (e.g., broadening participation).  Assesses needs and trends involving the social and economic sciences, implements overall strategic planning and policy setting for the Division, provides leadership and guidance to Division staff members, determines funding requirements, prepares and justifies budget estimates, balances program needs, allocates resources, oversees the evaluation of proposals and recommendations for awards and declinations, and represents NSF to relevant external groups.  Supervises and provides leadership and guidance to senior staff (Deputy Division Director), program officers, administrative and support personnel.  Fosters partnerships with other Divisions, Directorates, Federal agencies, scientific organizations, and the academic community.
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I'm a big fan of the NSF and the work it does, and very recently traveled to Washington D.C. to say thank you:

"And thank you to the NSF, and particularly to the Social, Behavioral and Economic Sciences Directorate, which must be one of the most cost-effective investments the government makes.  Social science isn’t very expensive, but it can be incredibly valuable. It can save lives.

"On a personal note, all of my work that was cited by the Nobel Prize committee was begun with funding from the NSF. Dan Newlon was the legendary director of the SBE Directorate, and he nurtured a generation of economists who made big changes in how economics is done. In the early 1990’s, when I was discouraged by the progress I was making on understanding matching, he encouraged me to stay the course. So for me, the NSF support was about much more than funding."
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Here's the set of my blog posts that mention the NSF

NAS report on The Value of Social, Behavioral, and Economic Sciences to National Priorities

As Congress continues to debate funding for science, here's a new report from the National Academies of Science: The Value of Social, Behavioral, and Economic Sciences to National Priorities:  A Report for the National Science Foundation

Two paragraphs on the uses of game theory and  market design caught my eye (you should be able to make them biglier by clicking on them...) :

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Update: here's the NSF news release on the NAS report:
New report concludes social, behavioral and economic sciences help advance national health, prosperity and defense
National Academies releases 'The Value of Social, Behavioral, and Economic Sciences to National Priorities'

"The full report mentions specific examples of NSF-supported SBE research that has advanced welfare, prosperity and security, including the creation of kidney exchange programs, improved cybersecurity and improved counterterrorism efforts.

"Like all sciences, the SBE sciences bring a rigorous, methodological approach to pursuing knowledge," the report states, noting that SBE scientists have contributed new methods of data collection and analysis now used by governments, researchers and business.

The National Academies will host a public discussion Wednesday, July 19, from 9 a.m.-12:30 p.m. EDT at its headquarters at 2101 Constitution Ave. NW, Washington, D.C."

Supporting science during the budget process: an op-ed in the St. Louis Post Dispatch

Here's an op-ed that ran this week in the St. Louis Post Dispatch:

Federally funded research helps connect transplant patients with donors
By Al Roth and Stuart Sweet

"To the nearly 5,000 people in our region and millions of Americans around the country suffering from kidney disease and waiting for a donor, federally funded research into obscure-sounding economic theory may turn out to be just what the doctor ordered.

As the president of the United Network for Organ Sharing Board of Directors and a Nobel Prize-winning economic researcher who did that work, we have seen first-hand how scientific research, even in seemingly unrelated fields, has the power to connect those suffering with disease with vital cures. And yet, the budget proposed by the current administration proposes to dramatically scale back on research, rather than double down on investments in potentially life-saving research.
...
"Thanks to research funded by the Navy and the National Science Foundation, spanning multiple decades, we’ve developed a system in which kidneys can be exchanged among pairs of donors and recipients who aren’t compatible with each other. How? We pair them, or in some cases, chain them together across multiple donor-recipient pairs, so that each patient gets a compatible kidney from another patient’s donor.

"This approach has saved thousands of lives and hundreds of millions of dollars. Recipients enjoy better quality of life, and every transplant saves the government more than a quarter of a million dollars in health care costs that would have gone to prolonged dialysis treatment.

"Over the past six years, the United Network for Organ Sharing has been running a pilot program to help incompatible donors find compatible pairs for kidney paired donation. In its first five years, the pilot program helped 155 patients receive a healthy kidney despite experiencing the heartbreak of finding out that the person willing to give them the incredible gift of a kidney was not a match.

"Policymakers from both sides of the aisle and around the country have long supported robust investment in basic and applied research that makes success stories like these possible. They have seen that across every industry and sector, investments in research have impacted everything from manufacturing to agriculture and national security, and innovations like kidney paired donation that ensure more Americans can live long, healthy lives.

"We particularly applaud Sen. Roy Blunt’s work as chairman of the Senate Appropriations Subcommittee on Labor, Health, and Human Services to increase research funding, especially for the NIH, and with his colleagues throughout the Congress to protect investments in research and development overall. We urge them to reassert that federal funding for science is an important investment in our nation’s future.

Dr. Stuart Sweet is a professor of pediatrics at Washington University, medical director of the pediatric lung transplant program at St. Louis Children’s Hospital and president of the United Network for Organ Sharing Board of Directors.

Alvin E. Roth is a professor of economics at Stanford University, shared the 2012 Nobel Prize in economics, and is the author of “Who Gets What and Why.”

Supporting science during the budget process--an op-ed in Alabama

Government funding of science is important, and at risk.  Here's an opinion piece that ran yesterday in Alabama, which seeks to bring some of the direct benefits in Alabama to the attention of Alabama's citizens and representatives in Washington (using the active kidney exchange program in Alabama as an example).

Trump budget puts future scientific advances at risk
By Alvin E. Roth, the Craig and Susan McCaw Professor of Economics at Stanford University
and Dr. Jayme Locke, Associate Professor at UAB School of Medicine and the Director of the Incompatible Kidney Transplant Program and Transplant Analytics, Informatics & Quality

Here are the final paragraphs:

"As the Director of the Incompatible Kidney Transplant Program at UAB and a Nobel Prize winning economic researcher, we have seen first-hand the power of science to connect those suffering with disease with vital cures.

We applaud Senator Shelby as a leader of the Senate Appropriations Committee, and Representatives Aderholt and Roby on the House Appropriations Committee, as well as all of the Alabama Congressional delegation on their work to support vital R&D investments in a bipartisan way.

We are hopeful that leaders will once again demonstrate that funding America's future innovation is a bipartisan imperative. "

Market Design, and NSF support of economics

Market design plays a role in the arguments both pro and con, in the recent symposium in the Journal of Economic Perspectives:

Symposium: NSF Funding for Economists

In Defense of the NSF Economics Program (#11) Robert A. Moffitt

Full-Text Access (Complimentary) | Supplementary Materials

A Skeptical View of the National Science Foundation's Role in Economic Research (#12) Tyler Cowen and Alex Tabarrok

Full-Text Access (Complimentary) | Supplementary Materials

 Moffitt mentions auction design, kidney exchange and school choice (with a more general reference to deferred acceptance clearinghouses) as beneficiaries of NSF funding. Cowen and Tabarrok single out auction design as something whose private benefits might argue against government funding: "Indeed, few areas in economics have been as privately remunerative as auction theory."

Support from the US-Israel Binational Science Foundation (BSF), and from the National Science Foundation (NSF)

The current newsletter of the US-Israel Binational Science Foundation has taken note of the early support that Ido Erev and I received from them, and I'm very happy to acknowledge it. I wonder how widespread are binational science foundations?

Alvin Roth's New Book and NPR Interview

"Roth is a pioneer in the field of game theory and experimental economics and in their application to the design of new economic institutions. Early in his career, he and Prof. Ido Erev from the Technion received BSF funding on three different occasions for their work on how reinforcement learning can make useful predictions in experimental games."

They also quote me in an NPR interview, about kidney exchange, saying
“I kind of think of economists as being helpers here,” he said. “We have some ideas, but we don't do any of the surgeries.”
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The NSF also takes note of the support it has given to Nobel laureates, and I am certainly grateful for the support I received:
NSF-funded Nobel Prize winners in science through 2015

ECONOMICS
1970 – Paul A. Samuelson*
1972 – Kenneth J. Arrow*
1973 – Wassily Leontief
1975 – Tjalling C. Koopmans
1978 – Herbert A. Simon
1980 – Lawrence R. Klein
1981 – James Tobin
1982 – George J. Stigler
1983 – Gerard Debreu
1985 – Franco Modigliani
1986 – James M. Buchanan Jr.
1987 – Robert M. Solow
1992 – Gary S. Becker
1993 – Robert W. Fogel, Douglass C. North
1994 – John C. Harsanyi, John F. Nash*
1995 – Robert E. Lucas
1997 – Robert C. Merton
1998 – Amartya Sen
1999 – Robert A. Mundell
2000 – James J. Heckman, Daniel L. McFadden
2001 – George Akerlof, Michael Spence, Joseph Stiglitz
2002 – Daniel Kahneman, Vernon Smith
2003 – Robert C. Engle, Clive W. Granger
2004 - Finn E. Kydland, Edward C. Prescott
2005 – Robert J. Aumann, Thomas C. Schelling
2006 – Edmund S. Phelps
2007 – Leonid Hurwicz, Eric Maskin and Roger Myerson
2008 – Paul Krugman
2009 – Elinor Ostrom, Oliver E. Williamson
2010 – Peter A. Diamond, Dale Mortensen
2011 – Thomas J. Sargent, Christopher A. Sims
2012 – Alvin E. Roth and Lloyd S. Shapley
2013 – Eugene F. Fama, Lars Peter Hansen, Robert J. Shiller
2014 – Jean Tirole
2015 – Angus Deaton

* Received NSF support after receiving Nobel Prize.

An attack on science, and a defense in the LA Times: Golden Geese versus Golden Fleece

Tiffany Field, who shared a Golden Goose Award (given "to groups of researchers whose seemingly obscure, federally-funded research had led to major breakthroughs"), comes to the defense of social science, in the Los Angeles Times, in reply to an op-ed arguing that taxpayers' money is being wasted.
Opinion Social science caricature sets back human progress
By TIFFANY M. FIELD

The Golden Goose award arose in reaction to attacks on Federal funding of science, and takes its name in part from Senator William Proxmire's 1975-88 "Golden Fleece Awards" which were intended to ridicule funded grant proposals with funny sounding names. 

House debates support for NSF, social science

The Chronicle of Higher Ed has the (gated) story: House GOP Allows Some Compromise in Bid to Focus NSF on Economic Value

"... in a sign of future compromise before the bill reaches the Democratic-controlled Senate, the Republican majority on the House Science Subcommittee on Research and Technology accepted nine separate Democratic amendments, including a partial retreat from plans to severely cut the NSF’s budget for social-science research.
...
"[Rep. Dan Lipinski of Illinois, the top Democrat on the subcommittee] listed economically valuable products of social-science research, including studies that help the police anticipate crime patterns and analyses that more efficiently match kidney donors and recipients. Reaching inside the NSF to set directorate-by-directorate budget limits—a practice that Congress already employs with the National Institutes of Health—"may open the door for partisan meddling from either side of the aisle," he said."