Gaming the health care system; David Cutler's concerns

 The eminent Harvard health economist  David Cutler is worried by, among other things, the takeover of many healthcare facilities by private equity

Financial Games in Health Care—Doing Well Without Doing Good, by David M. Cutler, , JAMA Health Forum. 2024;5(5):e241591. doi:10.1001/jamahealthforum.2024.1591

"One form of gaming is asset looting—businesses taking money out of health care and then extorting state governments to replenish the funds. In an earlier publication,1 Song and I discussed how this works. Typically, a private equity firm owning a hospital sells the land the hospital is on and agrees to lease it back to the hospital at a high interest rate. The money from the sale is paid out to private equity investors; the hospital is saddled with the debt. If the hospital cannot repay the loan, the private equity firm threatens to close the facility unless the government covers the debt. Quality suffers during this process. Quality indicators at hospitals and nursing homes bought by private equity firms worsened after these changes in ownership.

...

"A third gaming strategy involves “coding intensity” and “upcoding,” which is coding and billing for more complex (and thus more expensive) care. These practices seek to maximize risk-adjusted reimbursements based on diagnostic codes. With coding intensity, the insurer codes all diagnoses ever received by an individual so that disease-based reimbursement is higher. Medicare pays private plans based on the health risks of their enrollees (measured by reported diagnoses). Thus, private insurers participating in Medicare Advantage spend enormous sums to find and code additional diagnoses. Estimates are that coding intensity will cost Medicare $50 billion in 2024.⁶

...

However, addressing coding practices is challenging because it may encourage risk selection. If payments for care provided to a patient are less than the costs incurred for that patient, insurers and clinicians may seek to treat only profitable patients and drive away the unprofitable ones. There are countless ways to do this. At the plan level, leaving prestigious hospitals out of a network and putting expensive medications in high cost-sharing tiers will drive away sicker patients.^9,10 Clinicians engage in risk selection as well. Widespread nonparticipation in Medicaid is evidence of the consequences when profitability varies with patient insurance status.

Because setting optimal health care reimbursement is difficult, less scrupulous clinicians and insurers will always have incentives to cut corners. Recently, it seems that the norms preventing this tendency are fraying. Thus, policymakers need to deter the idea that doing well can come at the expense of doing good. Whenever possible, malfeasance must be prevented in advance and punished when it occurs. Such a strategy will require willpower on the part of policymakers, not just tough words."

Britain's Infected Blood Inquiry Report: Prime Minister's apology, and the benefits and perils of hindsight

 After the publication  yesterday of Britain's Infected Blood Inquiry Report, the UK's Prime Minister apologized to the nation. Here's the BBC story:

PM apologises after infected blood scandal cover-up  By Nick Triggle and Jim Reed, BBC News

"Prime Minister Rishi Sunak says he is truly sorry for the failures over the infected blood scandal, calling it a decades-long moral failure.

"He was responding to the public inquiry's report into the scandal, which has seen 30,000 people infected from contaminated blood treatments.

"It found authorities covered up the scandal and exposed victims to unacceptable risks.

"Mr Sunak described it as a "day of shame for the British state".

...

""Today's report shows a decades-long moral failure at the heart of our national life. I want to make a wholehearted and unequivocal apology."

"He said the attitude of denial was hard to comprehend and was to "our eternal shame".

...

Labour leader Sir Keir Starmer apologised too, describing it as one of the "gravest injustices" the country had seen and saying victims had "suffered unspeakably".

***********

I've now had the opportunity to read some of the (2000 page) report, and it leaves me in two minds.  On the one hand, as summarized in various news stories about the report, it deals with a long history during which British clinicians could have responded faster to growing evidence about hepatitis and HIV in the blood supply, and the various British governing coalitions could certainly have acknowledged earlier and more fully that people had been infected.

On the other hand, some of the harms to people who were infected by blood-borne pathogens are clearer in hindsight than they were at the times that they began to occur.

The cases of hemophila patients (many of them children, many of them at Treloar's, a school for disabled children including many with severe hemophilia) are particularly jarring.  Many of those children are no longer living, having been infected with HIV in the  1980's, before it was positively identified as the cause of AIDS (but after there was evidence that something in the blood carried the infection). The clotting factors (extracted from plasma pooled from many donors) that were being explored to treat hemophilia patients, are  (today standard treatments for hemophilia, but in the period covered by the report they were subjects of research, and were, tragically, infected with HIV, and hepatitis C before it's virus had been identified.

Here's a passage (from Vol. 1, p23) of the report that crystallizes why I think it's easier to assess blame in hindsight than it was at the time: (NANBH stands for non-A non-B Hepatitis, as Hep C was still something of a mystery.)

"By 1978 there were a number of reports showing that NANBH was linked to persistent liver damage. Amongst them was a paper published in September 1978 in The Lancet, authored by Dr Eric Preston and colleagues in Sheffield. In his oral evidence to the Inquiry, Dr Mark Winter said that this paper “blew out of the water instantly the idea that this [NANB hepatitis] was nothing to worry about because their study showed, as did other studies, that most of these patients had very significant chronic liver disease”. He thought doctors had been unwilling to think that NANBH might be a problem, because factor concentrate had brought “such spectacular benefits”: it was this reluctance to face the facts described in scientific journals that had prevented earlier acceptance of the seriousness of the problem."

The report also dwells on the difficulties that the UK faced in becoming self-sufficient in non-commercial plasma and clotting factor from domestic sources.  But self sufficiency is a world-wide problem today in states that depend on unpaid domestic donors. So it's not clear how culpable the British blood services should be considered on that account.

And it's a complicated question, because some of the U.S. commercial suppliers started heat treating their plasma to effectively destroy many pathogens, before this became common in the U.K.

The report states (Vol 1, p49)

"Some clinicians were reluctant to embrace commercial heat-treated products. There was as yet little direct evidence of how reliable the claims about commercial heat-treated products were in practice. Although there was no evidence of side-effects after a year of use in the US, heat-treated commercial products were not licensed for use in the UK until early in 1985. It is not difficult to see why clinicians may have preferred to wait for domestic product rather than change their treatment practices. Further, commercial products were believed to be more likely to carry hepatitis than domestic ones. Understandable though this reluctance may have been, it did not excuse continued use of unheated products beyond a short period into 1985."

So, British physicians were caught between desire for domestic plasma (from unpaid donors, which they believed was safer), and reluctance to use U.S. commercial plasma as it became the safer alternative.  And British plasma processors waited until 1985 to start producing their own heat treated plasma products. The results were tragic, but (unlike some of the later delays and evasions that the report spells out) I don't see that there is in every instance a clear case of blame.

The chair of the Infected Blood Inquiry is Sir Brian Langstaff , "a former judge of the High Court of England and Wales."  Judges have experience at hearing evidence, and may have some professional inclination to explain events in terms of guilt.  Not that there isn't plenty to apologize for.

#######

Here are all my posts on blood plasma.

Britain's Infected Blood Inquiry Report published today

 The UK commissioned a report on infections in its blood supply in the 1970's and 80's, and on the government's belated responses during and afterwards, as some 3,000 people died from HIV and other infections.  It's a long and complicated report, which came out today, and is available at

Infected Blood Inquiry Report

I've started to read it, and hope have more to say in a few days.  (It condemns many past decisions about maintaining the blood supply, providing medical care, and then failing to acknowledge past harms, which the current report is particularly aimed at addressing.)

In the meantime, here are some news reports.

From the BBC:

NHS and government covered up infected blood scandal By Nick Triggle and Jim Reed, BBC News

From the NYT:

Report Finds ‘Catalog of Failures’ in U.K. Contaminated Blood Scandal - A six-year inquiry found that the deaths of about 3,000 people and the infection of tens of thousands of others could have mostly been avoided.  By Aurelien Breeden  May 20, 2024

The labor market for OnlyFans chatters

 Here's a story by a professional writer and journalist, who appears to be a middle-aged dad, about his efforts to find and then master a job impersonating a 20-something female sex performer chatting with her fans on the website OnlyFans.

Wired has the story:

.I Went Undercover as a Secret OnlyFans Chatter. It Wasn’t Pretty. Your online influencer girlfriend is actually a rotating cast of low-wage workers. I became one of them. by BRENDAN I. KOERNER

"Like many of OnlyFans’ top earners, she had hired a management agency to help keep up with her customers’ demands for personal attention. “The chat specialists they give you, that was a huge deal for me,” she said. The agency provided a team of contractors whose sole job is to masquerade as the creator while swapping DMs with her subscribers. These textual conversations are meant to be the main way that OnlyFans users can interact with the models they adore.

"The existence of professional OnlyFans chatters wouldn’t have surprised me so much if I’d given just a few moments’ thought to the mathematical realities of the platform. OnlyFans has thrived by promising its reported 190 million users that they can have direct access to an estimated 2.1 million creators. It’s impossible for even a modestly popular creator to cope with the avalanche of messages they receive each day. The $5.6 billion industry has solved this logistical conundrum by entrusting its chat duties to a hidden proletariat, a mass of freelancers who sustain the illusion that OnlyFans’ creators are always eager to engage—sexually and otherwise—with paying customers.

...

"Gradually I realized that my best shot at understanding how chatters operate would be to join their ranks. As an English major who’s been fortunate enough to make a living with words for more than 20 years, I naively assumed I was qualified to land a gig. And as a writer, I was curious to learn what kind of artistry the job would require—what it takes to ensure that OnlyFans users never doubt they’re really interacting with the objects of their desire.

"AS I EMBARKED on my job hunt, I asked the owner of a top-tier OnlyFans agency for tips on how to make myself an appealing candidate. He was pessimistic about my odds of getting hired, mainly because I’m American. He said agencies tend to favor contractors who reside in lower-wage countries. That insight was borne out as I poked around the online communities where chatters find help-wanted ads; though the vast majority of OnlyFans users live in the US, the bulk of my competitors were based in places like the Philippines and Venezuela. Judging by their posts on the r/OnlyFansChatter subreddit and in an invite-only Facebook group, these workers are relatively well-educated, with university-level English and ace typing skills that some developed in high-pressure call centers. They also put up with all manner of abuses: OnlyFans agencies are notorious for stiffing their freelancers, forcing them to work 70-hour weeks, and summarily firing them if they miss a shift due to a power outage."

IVF for sex selection: legal in the U.S

Slate has the story:

The Parents Who Want Daughters—and Daughters Only. Sex selection with IVF is banned in much of the world. Not in the U.S. by Emi Nietfeld

"Sex selection was once controversial in the U.S. and is banned in almost every other country. Many Americans unaware of the process still assume that it’s that way. In reality, it has now become a standard part of IVF here. For some, the option to sex select is a perk of an otherwise exacting process. For others, it’s the whole point of doing IVF in the first place.

...

"Still, “the very act of sex selection is sexist,” argues Arianne Shahvisi, a professor of philosophy at Brighton and Sussex Medical School in the U.K., where elective sex selection is illegal.

...

"It’s not just the U.K. Virtually all the industrialized world—including Canada, Australia, and every European country besides Cyprus—bans sex selection except in rare medical cases. Most nations prohibit the practice on the grounds that it promotes sexism and that the children born from it may be harmed by gendered expectations. Widespread preference for a certain sex can also skew the population—as in India and China, where abortion and infanticide of girls have resulted in tens of millions more men than women. 

...

"In 1994 the American Society for Reproductive Medicine, the nonprofit that provides the industry’s professional guidelines, condemned sex selection for nonmedical reasons. Yet with no enforcement power, the guidelines remained just that. Unlike in most peer nations, IVF in America is mostly privately paid and weakly regulated. Instead, market forces dominate. By 2018, despite the ASRM’s recommendation that they not offer sex selection, 75 percent of clinics continued to provide the service. Since then, the ASRM’s ethics committee has updated its position to a neutral stance."

Top Trading Cycles (TTC) is characterized by strategy proofness and individual rationality on a large set, by Özgün Ekici

 Here's a very nice result about TTC:

 Pair-efficient reallocation of indivisible objects, by Özgün Ekici, Theoretical Economics 19 (2024), 551–564

Abstract: We revisit the classical object reallocation problem under strict preferences. When attention is constrained to the set of Pareto-efficient rules, it is known that top trading cycles (TTC) is the only rule that is strategyproof and individually-rational. We relax this constraint and consider pair-efficiency. A rule is pair-efficient if it never induces an allocation at which a pair of agents gain from trading their assigned objects. Remarkably, even in the larger set of pair-efficient rules, we find that TTC is still the only rule that is strategyproof and individually-rational. Our characterization result gives strong support to the use of TTC in object reallocation problems.

Sperm donation from Denmark to the UK and elsewhere

 The Daily Mail has the story:

'They invaded us once by boat and now they're doing it with sperm!' Why hundreds of British women are giving birth to 'Viking babies' conceived with Danish donors

"These are the main Danish export products - beer, Lego and sperm!"'

"So why are so many British women going Danish? According to Dr Alan Pacey, a fertility expert at the University of Sheffield, one of the reasons is a shortage of homegrown sperm.

'We don't have enough donors in the UK to meet the national need,' he explains. 'We don't have the clinic infrastructure sufficient to recruit enough donors - even when men want to donate.

...

"'The NHS is used to treating patients and you get a fee for treating patients. You don't get a fee for screening a donor that you may not ultimately accept.'

"Compounding the problem for British clinics is the 2005 law that forces men to waive their anonymity, meaning sperm donors face the prospect of offspring turning up on their doorstep once they reach the age of 18.

"Nevertheless, although Danish clinics, among them the world's largest sperm bank, Cryos, cannot sell semen from anonymous donors to British women, business is booming thanks to the huge numbers of local men happy to sign up anyway.

...

"Experts such as Laura Witjens, CEO of the National Gamete Donation Trust, say the excellent customer service deployed by Copenhagen's sperm banks has also contributed to the Viking baby boom.

'It's much easier for a British clinic to order sperm from Denmark which is Fed-exed the next day than to try and recruit their own donors and all the hassle that goes with them,' says Witjens.

'The Danish model is customer service driven. It knows how to deal well with customers, it has a good website, and that's what we could do in the UK as well - it's not rocket science.'

HT: Mario Macis

Increasing the supply of transplantable organs, in the long term, and sooner.

 Here's an article on the website of The American Council on Science and Health, on technologies that might eventually replace the need for human organ transplants, and on policies to increase their supply while still needed.

We Urgently Need More Organs For Transplantation. Science And Policy Can Come To The Rescue. By Henry I. Miller, MS, MD and Sally Satel, MD

"Both scientific and policy advancements could provide desperately needed organs for transplantation. For example, there have been some promising early studies using kidneys from pigs genetically engineered to prevent rejection, but a policy change – paying human donors for donating organs – could be implemented immediately and would be a game changer.

...

"[A] sector of medicine that desperately needs breakthroughs is the transplantation of solid organs, which are in severely short supply. Currently, more than 100,000 Americans are waiting for transplants, and due to a shortage of hearts, lungs, livers, and kidneys, at least 17 die each day. Donor organs — from a living person or cadaver — must match the rejection recipient’s tissue type and size; they are often not perfect. By one estimate, approximately half of transplanted organs are rejected by recipients’ bodies within 10-12 years, despite a constantly expanding understanding of what causes rejection. Another obstacle is that the organ procurement system in the U.S. is inefficient, inconsistent, and unaccountable – in short, a mess that causes preventable deaths.

"We are making progress, but too slowly. Two new high-tech approaches to providing organs for transplantation might ultimately both eliminate the need for organ donors and reduce the risk of tissue rejection. And there is also a low-tech approach that would require only a tweak in healthcare policy.

"Organs produced by 3D bioprinting"

...

"Organs from genetically modified pigs"

...

"The low-tech policy approach

"Although friends and relatives and even the occasional “good Samaritan” donor can donate kidneys, they must be given without compensation. Under section 301(a) of the National Organ Transplant Act of 1984 (NOTA), it is a federal crime for “any person to knowingly acquire, receive, or otherwise transfer any human organ for valuable consideration for use in human transplantation if the transfer affects interstate commerce.”  Therefore, we propose a federal tax credit for living donors willing to save the life of a stranger. The value of the reward should be between $50,000 and $100,000, which physicians and others who endorse donor compensation believe would be sufficient to address the organ shortage. An economic analysis published in 2022 estimated that a reward of $77,000 could encourage sufficient donations to save 47,000 patients annually.

"The credit would be universally available—refundable in cash for people who do not owe income tax, not phased out at high-income levels, and available under the alternative minimum tax. NOTA’s restriction on payments by organ recipients and other private individuals and organizations would not change—it would still be illegal for recipients to buy organs.

"A qualified organ donation would be subject to stringent safeguards. As all donors are now, prospective compensated donors would be carefully screened for physical and emotional health. A minimum six-month waiting period before the donation would filter out impulsive donors and donations by financially desperate individuals seeking instant cash.

"In addition to saving lives, the credit would save the government money, perhaps as much as $14 billion per year, by reducing expenditures on dialysis. Thus, donors would receive financial compensation from the government for contributing to the public good and bearing the risk of a surgical operation to remove the organ.

"This would be a compassionate and pragmatic policy. Moreover, it could be implemented immediately, rapidly clearing much of the backlog of Americans waiting for organs in advance of the longer-term high-tech approaches.

"The organ shortage kills thousands of Americans every year. We must do all we can to alleviate it now."

HT: Frank McCormick

Interviews with school choice stakeholders

 Here's a paper about school choice in New Orleans, organized around interviews with New Orleans "Experts and Administrators" on the one hand and "Activists and Educators" on the other. 

Akchurin, Maria, and Gabriel Chouhy. "Designing Better Access to Education? Unified Enrollment, School Choice, and the Limits of Algorithmic Fairness in New Orleans School Admissions." Qualitative Sociology (2024): 1-43.

Abstract: "Economic sociologists have long recognized that markets have moral dimensions, but we know less about how everyday moral categories like fairness are reconciled with competing market principles like efficiency, especially in novel settings combining market design and algorithmic technologies. Here we explore this tension in the context of education, examining the use of algorithms alongside school choice policies. In US urban school districts, market design economists and computer scientists have applied matching algorithms to build unified enrollment (UE) systems. Despite promising to make school choice both fair and efficient, these algorithms have become contested. Why is it that algorithmic technologies intended to simplify enrollment and create a fairer application process can instead contribute to the perception they are reproducing inequality? Analyzing narratives about the UE system in New Orleans, Louisiana, USA, we show that experts designing and implementing algorithm-based enrollment understand fairness differently from the education activists and families who use and question these systems. Whereas the former interpret fairness in narrow, procedural, and ahistorical terms, the latter tend to evaluate fairness with consequentialist reasoning, using broader conceptions of justice rooted in addressing socioeconomic and racial inequality in Louisiana, and unfulfilled promises of universal access to quality schools. Considering the diffusion of “economic styles of reasoning” across local public education bureaucracies, we reveal how school choice algorithms risk becoming imbued with incommensurable meanings about fairness and justice, compromising public trust and legitimacy. The study is based on thirty interviews with key stakeholders in the school district’s education policy field, government documents, and local media sources."

"Designing and implementing algorithm-based UE systems entails complex moral and political considerations, including questions about how to operationalize what is fair when giving priority to some students over others. The designers and supporters of these systems argue that, by automating and randomizing assignments to oversubscribed schools, UE algorithms are not only efficient, but also impartial and, therefore, value-neutral. Yet as policy instruments, their use is explicitly predicated on normative grounds: centralized enrollment platforms seek to make choice more transparent and fair, which in practice means weakening the influence of social privileges in access to educational opportunities. But even if UE systems constitute powerful technologies that deliver simple and efficient enrollment across the board, providing greater access to school choice, is it possible that they still end up eroding public trust and contributing to the perception they are reproducing inequality? And if so, why?

,,,

"We argue that a crucial reason why technically irreproachable policy instruments like UE algorithms may fall short of eliciting sufficient moral consensus and become enmeshed in political disputes is that core values like fairness are defined and interpreted differently across the contexts where such instruments are created and used.

...

"We examine the multivalent meanings of algorithmic fairness through a study of OneApp, the unified enrollment system developed more than a decade ago in New Orleans, Louisiana (NOLA).Footnote1 Well-known as a national exemplar of market-based school reform, New Orleans is unique in that all the city’s public-school students now attend charter schools, a radical experiment widely celebrated by the school reform movement that has nevertheless elicited heated debate. Our study shows that a paradigmatic clash has emerged between how fairness in the enrollment process is understood “from above” and “from below.” Fairness tends to be interpreted in narrow, procedural, and ahistorical terms by education experts who design and shepherd UE through implementation, even if many do imbue UE with the normative purpose of limiting the influence of social privilege in access to school choice. By contrast, education activists tend to evaluate fairness with consequentialist reasoning and in terms of broader conceptions of justice rooted in addressing the history of socioeconomic and racial inequality in New Orleans, and the unfulfilled promise of access to quality schools for all. From a top-down perspective, then, UE algorithms are seen as a positive step towards making the school system a more equitable marketplace. In this view, an algorithm-based enrollment system plays a critical role in the democratization of choice. Seen from below by those left out, however, the same algorithms legitimize an inherently unjust market system where chance still determines (unequal) access to educational opportunity. Moreover, the fact that parents need to participate in an algorithmic process instead of directly enrolling their kids in a good-quality neighborhood school signals the absence of real equity.

...

"promoting choice options such as charter schools has yielded benefits to both students who enroll in them and—via competitive effects—those who attend schools nearby (Berends 2015; Jabbar et al. 2022) in some (but not all) cases. On the other hand, researchers have also warned that choice policies can exacerbate existing inequalities, insofar as access to valued information, social networks, and resources are crucial for capitalizing on the new opportunities that become available in a more competitive marketplace

...

“market design” is perhaps the specialization area that most enthusiastically embodies the “performative” aspect of economics practice—the idea that economists not only describe markets but also perform them through sociotechnical devices (Caliskan and Callon 2009; Callon 1998; MacKenzie and Millo 2003).  ... For too long, the design of “fair”, “efficient”, and “transparent” UE algorithms has remained a technical matter in the hands of experts, not an object of study worth analyzing from sociological, political, or even philosophical standpoints.

...

"Interviews consisted of a semi-structured component following an interview guide and a component relying on vignettes designed to compare how our interviewees conceptualize fairness across the same four scenarios. After the first part of the interview, we typically took turns reading vignettes aloud and asking the same set of follow-up questions to our respondents. For example, the first scenario describes Malcolm, a hypothetical student whose family uses OneApp to apply to elementary school and he gets his fifth-choice school, which is rated a C. We then ask respondents to evaluate whether Malcolm has been treated fairly, gradually adding new information about his socioeconomic status, racial background, and disability status.

...

"In this study, we do not rely on statistical sampling logic and do not seek to make generalizable claims about perceptions of fairness regarding OneApp among all administrators or all NOLA families using this UE system. Instead, we aim to show how studying an algorithmic tool reveals how experts and community leaders embedded in the same education policy field have different ways of conceptualizing and talking about fairness. 

...

"For instance, when we described the experience of a hypothetical student, Malcolm, whose parents used OneApp to apply to elementary school last year, many respondents rejected the notion of procedural fairness outright. In the scenario, Malcolm and his family had secured a spot in a school with the letter grade C that was their fifth preference. When we asked our respondents whether Malcolm had been treated fairly, one respondent from an education justice organization replied, “No, I don’t think it’s fair and it makes me wonder what is a better way because [the explanation we hear is], ‘We need more quality seats.’ I’m like, ‘Oh really? How are we going to get there?’ Because we want more quality seats” 

#########

The article goes on to point out that the school district hasn't published the algorithm code or flow charts, which adds to suspicions of unfairness.  My inclination is that such things should be in the public domain, which might help the discussion focus on the very different issues of how schools are assigned, and why not all schools are first rate.

Simulating European kidney exchange, by Druzsin, Biró, Klimentova, and Fleiner

There are a big variety of procedures used for kidney exchange in Europe.  Here are a set of simulations meant to explore their effects.

Druzsin, Kristóf, Péter Biró, Xenia Klimentova, and Rita Fleiner. "Performance evaluation of national and international kidney exchange programmes with the ENCKEP simulator." Central European Journal of Operations Research (2024): 1-21.

"we are aware of four international KEPs running worldwide:

• Czech-Austrian-Israeli collaboration,

• KEPSAT involving Italy, Portugal, Spain,

• STEP, run by Scandiatransplant,

• NZKX by Australia and New Zealand.

One of the main aspects that can differ in between international KEPs is collaboration polices. In KEPSAT each of the three countries conducts a national matching run first, and only after that they seek for international cycles in the remaining pools. The other three international KEPs merge their pools and conduct one single matching run."

#######

Not surprisingly, maximizing domestic kidney exchange first leaves only hard to match pairs, which limits the effectiveness of international cooperation.  A 2023 paper from Portugal reports that, since 2017, only three Portuguese pairs were matched in the KEPSAT program with Spain and Italy.

Tuesday, March 12, 2024

Kidney exchange between Portugal and Spain, and prospects for global kidney exchange

Talks to doctors and students in Italy

 I just returned from a busy trip to Italy, that began with a talk to physicians in Rome about kidney exchange, after which I moved on to talk to students in Padua.

Both were fun in different ways.  Here are some of the students gathered for a spritz after one of my talks in Padua.

Richard Slayman: first recipient of pig kidney transplant dies after two months. (RIP)

 Here's the story from the Guardian:

Pig kidney ‘xenotransplant’ patient dies two months later. No indication that Richard ‘Rick’ Slayman’s receipt of genetically modified kidney caused his death, says Massachusetts transplant team

"The first recipient of a genetically modified pig kidney transplant has died about two months later, with the hospital that performed the surgery saying it did not have any indication the transplant was the cause.

...

"In a statement, Slayman’s family thanked his doctors. “Their enormous efforts leading the xenotransplant gave our family seven more weeks with Rick, and our memories made during that time will remain in our minds and hearts,” the statement said.

"They said Slayman underwent the surgery in part to provide hope for the thousands of people who need a transplant to survive. “Rick accomplished that goal and his hope and optimism will endure forever.”

"In April, New Jersey woman Lisa Pisano also received a genetically modified pig kidney as well as a mechanical pump to keep her heart beating.

########

I'm not aware of any medical journal reports so far on these transplants--reporting has just been by press release...

Jim Simons (1938-2024)

 Jim Simons, the great investor and philanthropist of math and computer science, died yesterday.

Here's the announcement from the Simons Foundation.

Simons Foundation Co-Founder, Mathematician and Investor Jim Simons Dies at 86

And here's the NYT:

Jim Simons, Math Genius Who Conquered Wall Street, Dies at 86. Using advanced computers, he went from M.I.T. professor to multibillionaire. His Medallion fund had 66 percent average annual returns for decades.

Kidney exchange in Germany?

 A draft law to make kidney exchange legal in Germany, and to allow nondirected donation, is making some progress: here (with the help of Google Translate) is a news story on the proposed new law.

Living kidney donation should be made easier

"In order to reduce the organ shortage in Germany, Federal Health Minister Karl Lauterbach (SPD) wants to make living kidney donations easier. This emerges from a draft amendment to the Transplantation Act. The Star first reported.

"According to the draft, the previously prescribed “proximity ratio” for so-called cross donations will no longer apply in the future. To date, couples in which one person wants to donate a kidney to the other but this is not possible due to incompatibility are only allowed to “cross-donate” with another couple in a comparable situation if there is a close relationship between the couples. This is intended to prevent organ trafficking and commercialization.

"In the future, this cross donation could be made without proximity, thereby significantly expanding the circle of recipients. According to the draft bill, the donation should be anonymous and organized by transplant centers. The aim of anonymity is to prevent money from being paid for an organ.

"Anonymous kidney donations should also be possible in principle. In the future, people in Germany could donate a kidney for selfless reasons without knowing who it is going to. In countries like the USA, this option has existed for a long time."

HT: Dorothea Kubler

The design of markets, in Padua (video)

Yesterday I had the pleasure of speaking about market design in the Aula Magna of the University of Padua, where Galileo lectured.  Below is a video. I start to speak around minute 14:20.

Update: here's a post-talk photo:

Ignazio Marino is running for the EU Parliament

 When in Rome, I met with Ignazio Marino (transplant surgeon, former Mayor of Rome) who is now running for the EU Parliament.  He posted a 1 minute video on his various social media accounts of our conversation about his hopes for kidney exchange in Europe.

https://www.facebook.com/share/v/kKA4y38ZSKfkm6Rg/?mibextid=WC7FNe

 

https://x.com/ignaziomarino/status/1787469504563315115?s=48

 

https://www.instagram.com/reel/C6oYf1CicYw/?igsh=aGtheDc0cGxtZ3c4

 

Kidney exchange in Italy, Europe and the U.S.: video of my talk in Rome

 Here is a video recording of my talk in Rome yesterday at the  Istituto Superiore di Sanità. There are some introductions by people with vast accomplishments in Italian transplantation and kidney exchange, Giuseppe Feltrin (director of the National Transplant Center), Antonio Nicolò (professor of Economic Theory at the University of Padua) and Lucrezia Furian (Kidney and Pancreas Transplant Surgery Unit - Department of Surgical, Oncological and Gastroenterological Sciences of the University Hospital of Padua)*. 

My talk begins at 27:55.

x

*Although her web page didn't yet reflect this, Dr. Furian was very recently promoted to the rank of Full Professor of Surgery.  Congratulations Lucrezia!

The Design of Markets. Una Nobel Lecture (Two talks in Padua, on Tuesday and Wednesday)

 Following my talk in Rome today, I'll be speaking in Padua tomorrow and Wednesday, first giving a seminar on controversial markets, and then a public lecture on market design.

The Design of Markets. Una Nobel Lecture di Alvin Eliot Roth

"On Wednesday 8 May the University of Padua hosts the  Nobel Lecture

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"The meeting opens with greetings from the vice-rector Antonio Parbonetti  and the director of the Galilean School of Higher Studies,  Gianguido Dall'Agata . The guest is introduced by Antonio Nicolò , coordinator of the Social Sciences Class of the Galilean School.

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"The Nobel Lecture, which is held in English , is  open to the public . To participate, reservations are required 

You can also follow the meeting via  live streaming on YouTube .

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The Padua Nobel Lecture by Alvin Eliot Roth is preceded, on Tuesday 7 May at 3pm, by a seminar aimed exclusively at professors, researchers, fellows of the Department of Economic Sciences of the University of Padua - dSEA .
The Economics Seminar  is entitled " Controversial markets and repugnant transactions " and is held at the department headquarters in via del Santo 33 in Padua.

Baby formula and U.S. supply chains

 Martha Gershon points me to her latest column, to be followed in due time by a book on feeding babies in America.

The U.S. needs a reliable supply of baby formula. A new bill in Congress can help      By Martha Gershun and Rosa DeLauro  May 2, 2024

"Here’s the background: In February 2022, Abbott recalled three brands of its baby formula after four babies became sick with bacterial infections after consuming the company’s formula. When a Food and Drug Administration inspection uncovered traces of a potentially deadly bacteria in Abbott’s main production plant in Sturgis, Mich., the company shut down the plant, which at the time produced more than 40% of U.S. formula. The shutdown caused cascading supply chain problems, creating a severe shortage of baby formula that lasted more than a year."

Free speech and universities

 At Stanford, recent event are helping us remember that our speech policy is the First Amendment.

That hasn't always been front of mind at Stanford, and now that it is, it is still distressing to see a student wearing a Hamas headband on campus, but it's worth remembering that freedom of speech is important, and important at universities. (The First Amendment is generally understood to also imply freedom of association, so you should feel free not to hire a Hamas supporter who graduates from Stanford.)

Here's the First Amendment:

Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press; or the right of the people peaceably to assemble, and to petition the Government for a redress of grievances.

Because the First Amendment only restricts government from abridging the freedom of speech, private universities (although not public ones) are entitled to have more restrictive speech codes.  But in California, the 1992 Leonard Law forbids private secular universities from restricting student speech  protected by the First Amendment.

In 1994, a court ruled (in the case of Corry v. Stanford) that a Stanford prohibition of certain "fighting words" when addressed to individuals violated the Leonard Law. Stanford's then president, Gerhard Casper, subsequently addressed the faculty senate, giving his thoughts on speech at a university:

Statement on Corry vs. Stanford University (by Gerhard Casper)

Here are his concluding sentences:

"Harassment, threats or intimidation continue to be unacceptable. Should they go beyond what is protected by law, we will invoke university disciplinary procedures. Otherwise, we shall continue to do what we always have done. We shall counter prejudice with reason. The work of reason is hard work, as is the work of building and maintaining a great private university. I invite all faculty, students and staff to continue the work of reason."