Catherine Rampell at the NY Times has the story, focusing on the startup Knack: Your Next Job Application Could Involve a Video Game
Sunday, February 2, 2014
Saturday, February 1, 2014
Counterproductive incentives in transplantation
Which would be better, to have a transplant center transplant 200 patients and have 150 do well, or to have the center transplant 100 patients and have all of them do well? How about if the 100 patients who didn't receive a transplant in the second scenario would all have died?
In Oregon, The Bend Bulletin has a three part series (pointed out to me by Ben Hippen) on the difficulties of regulating transplant centers, and the sometimes counterproductive incentives that are introduced (in an effort to counteract other bad incentives that hospitals may have).
UPMC, the University of Pittsburgh Medical Center, comes out looking very good, incidentally.
Patients denied transplants as donor organs are discarded
PART 1: Centers forced to focus on benchmarks rather than patients
By Markian Hawryluk
"Patients who need organ transplants are dying even while viable organs are being thrown out, as government regulations have forced transplant centers to focus on overall survival rates instead of the well-being of individual patients.
"The rules implemented by the Medicare program, which pays for the vast majority of organ transplants in the U.S., evaluate transplant centers based on the one-year patient and organ survival rates after transplant. Centers that fall below benchmarks could be shut down or forced into a lengthy and expensive remedial process.
That has prompted many centers to choose healthier patients and higher quality organs to transplant. High-risk patients that could pull down a center’s overall survival rate are often unable to get on the transplant list, or end up dying on the waiting list as centers pass on marginal but still usable kidneys, livers and lungs. And the decades-long growth in the number of transplants performed in the U.S. has plateaued since the regulations were implemented.
“The side effect has been to turn people risk averse,” said Dr. Dorry Segev, a transplant surgeon at Johns Hopkins Medical Center, “to the point where patients who would benefit from transplant are being denied transplants, and to the point where organs that are beneficial to patients are discarded.”
The regulations have caused centers to take a hard look at their quality-improvement mechanisms and how they evaluate patients and organs for transplant.
Programs became acutely aware of their survival rates, which began to climb after the rules went in effect in 2007.
The percentage of hearts still beating one year after transplant hit an all-time high of 91 percent in 2010, up from 88 percent in 2003; 85 percent of transplant lungs were still breathing, up from 80 percent in 2003. Deceased donor kidney transplants have achieved an astonishing 93 percent success rate.
"Transplant surgeons routinely credit the regulations with strengthening the transplant system and for the most part, improving the quality of care for transplant patients.
“There is no question we have a healthier system and a more monitored system than we did before these regs came out,” said Dr. Michael Abecassis, director of the transplant center at Northwestern University in Chicago.
The unintended consequence, he said, is that centers are “cherry-picking” their patients.
“Patients might die and not get transplanted even though they may have an 80 percent chance of survival,” Abecassis said. “If the target is 90 percent, or you’re going to get flagged, you may look at 80 and say, ‘I’m not going to do that.’ Well, if you’re the patient, it’s 80 versus zero. Then 80 is pretty good.”
...
"Before the regulations went into effect, the number of transplants in the U.S. had grown each year. But in 2007, the first year centers were being held to the survival benchmarks, the number of transplants dropped and has remained flat ever since."
****************
Transplant centers pull back to avoid sanctions
PART 2: High-risk patients can put programs in jeopardy
"The new regulations, known as the Medicare Conditions of Participation, or COPs, were finalized in 2005 after a series of highly public transplant scandals. Reports of wait-list irregularities, diversions of organs and major medical errors spurred CMS officials to step in and establish regulations for what primarily had been a self-regulated field.
"CMS, the largest purchaser of transplants in the world (with the possible exception of China), adopted metrics originally developed by the transplant industry itself. Years earlier, the United Network for Organ Sharing’s Organ Procurement and Transplant Network had set up a flagging system to help identify and improve programs with subpar results.
But while that flagging system relied on peer review and public disclosure, the CMS regulations threaten to shut down centers that don’t improve.
Centers whose number of patient deaths or organ failures exceed 150 percent of what would be expected for their mix of patients are flagged. Multiple flags within a 21⁄2-year period trigger CMS action.
Centers then have 210 days in which to explain the mitigating factors that led to their low survival rates. If programs can improve by the end of that period, they are allowed to continue operating as usual. In other cases, CMS will acknowledge the mitigating circumstances and grant exceptions.
The centers that can’t improve quickly or convince CMS to grant an exception are given three options: shut down voluntarily, shut down involuntarily, or enter into a systems improvement agreement, or SIA. Through August 2012, 127 of the nation’s 330 transplant centers were flagged twice and investigated by CMS, including the programs at Hopkins.
*****************
Transplantable organs go to waste
PART 3: Centers feel regulatory pressure to avoid non-ideal organs
"Transplant programs may have to make do with more marginal organs going forward. Ideal organs generally come from young, healthy individuals who incur a traumatic death. Those types of donors are becoming less common, due to gains in highway safety and medical advances that can save accident victims from brain death. A Canadian study released in October found that the percentage of patients with brain injuries who eventually were declared brain dead fell from a high of 9.6 percent in 2004, to 2.2 percent in 2010.
"Donations after brain death accounts for half of kidney transplants, three-quarters of liver transplants, 90 percent of lungs, and all hearts. But that is changing.
"An increasing proportion of organs are coming from patients whose hearts stopped beating before the other organs could be recovered, or from older, sicker donors. Both categories of organs have a lower chance of surviving one year after transplant.
“We are seeing more and more organs sitting in that category of marginal organs,” Alexander said.
"Expanded-criteria donor kidneys (ECD), for example, have an 82 percent one-year survival rate, compared with 90 percent for a standard-criteria kidney. A kidney procured from a brain-dead donor has a 91 percent one-year survival rate, while those recovered from donors after cardiac death (DCD) have an 89 percent rate.
"When patients are listed for transplant, they are usually presented with a menu of organ types, each with different risk profiles, and asked to choose what types of organs they would accept. When organs become available, doctors and transplant coordinators decide whether they are willing to transplant that organ into that patient and whether to pass on that offer to the patient.
"Studies show that in aggregate, transplant candidates who accept ECD kidneys do better over the long run than patients who wait on dialysis for a more ideal kidney. While standard kidneys last an average of 10 years post-transplant, ECD kidneys average five.
...
"Yet marginal and high-risk organs are routinely turned down. An analysis of organ sharing data by surgeons at the University of California, San Francisco, found that 84 percent of patients who died waiting for a liver had received at least one organ offer and an average of six offers. Most were declined by the surgeons due to donor age or quality of organ.
“Wait-list deaths are not simply due to lack of donor organs as many of us assume,” lead author Dr. John Roberts said, citing the stigma of non-ideal livers.
"When surgeons become more selective about marginal organs, it can quickly result in a snowball effect. When an organ becomes available it is offered electronically to centers in the region and across the country. The more centers decline an organ, the more surgeons with patients lower down the list begin to wonder why the organ has been passed on so many times. And with each refusal, the time the organ sits on ice and degrades in quality increases. Kidneys can still be transplanted up to 48 hours after being put on ice, livers less than a day. If no center is willing to take a chance, eventually the organ is simply thrown out.
“Our system is pretty slow,” Roberts said. “It works well for good organs. It doesn’t work that well to get not-so-good organs broadly distributed.”
In Oregon, The Bend Bulletin has a three part series (pointed out to me by Ben Hippen) on the difficulties of regulating transplant centers, and the sometimes counterproductive incentives that are introduced (in an effort to counteract other bad incentives that hospitals may have).
UPMC, the University of Pittsburgh Medical Center, comes out looking very good, incidentally.
Patients denied transplants as donor organs are discarded
PART 1: Centers forced to focus on benchmarks rather than patients
By Markian Hawryluk
"Patients who need organ transplants are dying even while viable organs are being thrown out, as government regulations have forced transplant centers to focus on overall survival rates instead of the well-being of individual patients.
"The rules implemented by the Medicare program, which pays for the vast majority of organ transplants in the U.S., evaluate transplant centers based on the one-year patient and organ survival rates after transplant. Centers that fall below benchmarks could be shut down or forced into a lengthy and expensive remedial process.
That has prompted many centers to choose healthier patients and higher quality organs to transplant. High-risk patients that could pull down a center’s overall survival rate are often unable to get on the transplant list, or end up dying on the waiting list as centers pass on marginal but still usable kidneys, livers and lungs. And the decades-long growth in the number of transplants performed in the U.S. has plateaued since the regulations were implemented.
“The side effect has been to turn people risk averse,” said Dr. Dorry Segev, a transplant surgeon at Johns Hopkins Medical Center, “to the point where patients who would benefit from transplant are being denied transplants, and to the point where organs that are beneficial to patients are discarded.”
The regulations have caused centers to take a hard look at their quality-improvement mechanisms and how they evaluate patients and organs for transplant.
Programs became acutely aware of their survival rates, which began to climb after the rules went in effect in 2007.
The percentage of hearts still beating one year after transplant hit an all-time high of 91 percent in 2010, up from 88 percent in 2003; 85 percent of transplant lungs were still breathing, up from 80 percent in 2003. Deceased donor kidney transplants have achieved an astonishing 93 percent success rate.
"Transplant surgeons routinely credit the regulations with strengthening the transplant system and for the most part, improving the quality of care for transplant patients.
“There is no question we have a healthier system and a more monitored system than we did before these regs came out,” said Dr. Michael Abecassis, director of the transplant center at Northwestern University in Chicago.
The unintended consequence, he said, is that centers are “cherry-picking” their patients.
“Patients might die and not get transplanted even though they may have an 80 percent chance of survival,” Abecassis said. “If the target is 90 percent, or you’re going to get flagged, you may look at 80 and say, ‘I’m not going to do that.’ Well, if you’re the patient, it’s 80 versus zero. Then 80 is pretty good.”
...
"Before the regulations went into effect, the number of transplants in the U.S. had grown each year. But in 2007, the first year centers were being held to the survival benchmarks, the number of transplants dropped and has remained flat ever since."
****************
Transplant centers pull back to avoid sanctions
PART 2: High-risk patients can put programs in jeopardy
"The new regulations, known as the Medicare Conditions of Participation, or COPs, were finalized in 2005 after a series of highly public transplant scandals. Reports of wait-list irregularities, diversions of organs and major medical errors spurred CMS officials to step in and establish regulations for what primarily had been a self-regulated field.
"CMS, the largest purchaser of transplants in the world (with the possible exception of China), adopted metrics originally developed by the transplant industry itself. Years earlier, the United Network for Organ Sharing’s Organ Procurement and Transplant Network had set up a flagging system to help identify and improve programs with subpar results.
But while that flagging system relied on peer review and public disclosure, the CMS regulations threaten to shut down centers that don’t improve.
Centers whose number of patient deaths or organ failures exceed 150 percent of what would be expected for their mix of patients are flagged. Multiple flags within a 21⁄2-year period trigger CMS action.
Centers then have 210 days in which to explain the mitigating factors that led to their low survival rates. If programs can improve by the end of that period, they are allowed to continue operating as usual. In other cases, CMS will acknowledge the mitigating circumstances and grant exceptions.
The centers that can’t improve quickly or convince CMS to grant an exception are given three options: shut down voluntarily, shut down involuntarily, or enter into a systems improvement agreement, or SIA. Through August 2012, 127 of the nation’s 330 transplant centers were flagged twice and investigated by CMS, including the programs at Hopkins.
*****************
Transplantable organs go to waste
PART 3: Centers feel regulatory pressure to avoid non-ideal organs
"Transplant programs may have to make do with more marginal organs going forward. Ideal organs generally come from young, healthy individuals who incur a traumatic death. Those types of donors are becoming less common, due to gains in highway safety and medical advances that can save accident victims from brain death. A Canadian study released in October found that the percentage of patients with brain injuries who eventually were declared brain dead fell from a high of 9.6 percent in 2004, to 2.2 percent in 2010.
"Donations after brain death accounts for half of kidney transplants, three-quarters of liver transplants, 90 percent of lungs, and all hearts. But that is changing.
"An increasing proportion of organs are coming from patients whose hearts stopped beating before the other organs could be recovered, or from older, sicker donors. Both categories of organs have a lower chance of surviving one year after transplant.
“We are seeing more and more organs sitting in that category of marginal organs,” Alexander said.
"Expanded-criteria donor kidneys (ECD), for example, have an 82 percent one-year survival rate, compared with 90 percent for a standard-criteria kidney. A kidney procured from a brain-dead donor has a 91 percent one-year survival rate, while those recovered from donors after cardiac death (DCD) have an 89 percent rate.
"When patients are listed for transplant, they are usually presented with a menu of organ types, each with different risk profiles, and asked to choose what types of organs they would accept. When organs become available, doctors and transplant coordinators decide whether they are willing to transplant that organ into that patient and whether to pass on that offer to the patient.
"Studies show that in aggregate, transplant candidates who accept ECD kidneys do better over the long run than patients who wait on dialysis for a more ideal kidney. While standard kidneys last an average of 10 years post-transplant, ECD kidneys average five.
...
"Yet marginal and high-risk organs are routinely turned down. An analysis of organ sharing data by surgeons at the University of California, San Francisco, found that 84 percent of patients who died waiting for a liver had received at least one organ offer and an average of six offers. Most were declined by the surgeons due to donor age or quality of organ.
“Wait-list deaths are not simply due to lack of donor organs as many of us assume,” lead author Dr. John Roberts said, citing the stigma of non-ideal livers.
"When surgeons become more selective about marginal organs, it can quickly result in a snowball effect. When an organ becomes available it is offered electronically to centers in the region and across the country. The more centers decline an organ, the more surgeons with patients lower down the list begin to wonder why the organ has been passed on so many times. And with each refusal, the time the organ sits on ice and degrades in quality increases. Kidneys can still be transplanted up to 48 hours after being put on ice, livers less than a day. If no center is willing to take a chance, eventually the organ is simply thrown out.
“Our system is pretty slow,” Roberts said. “It works well for good organs. It doesn’t work that well to get not-so-good organs broadly distributed.”
Friday, January 31, 2014
Stanford Connects in Pasadena, Feb 1
Expand your mind—and your network
Ready to meet President Hennessy, world-class faculty and hundreds of Stanford alums from Los Angeles and beyond?
Who Gets What? The New Economics of Matching and Market Design
Professor Roth addresses recent developments in market design, for which he shared the 2012 Nobel Memorial Prize in Economics. He suggests ways to think about why some transactions may be regarded as repugnant, and how we might think about what are free markets.
Thursday, January 30, 2014
Dental residency match results
Elliott Peranson, who runs National Matching Services in Toronto, apparently has fond memories of our trip to Stockholm: here is the news release about the results of the recent Postdoctoral Dental Matching Program
Assignment of Dental Residency Positions Made with Nobel Prize Algorithm
The results released today by National Matching Services for the Postdoctoral Dental Matching Program placed 1721 applicants into postdoctoral dental residency positions. The Matching Program uses a mathematical algorithm to create a fair, transparent and efficient recruitment process.
"The results of the 29th annual Postdoctoral Dental Matching Program (the “Match”) were released today by National Matching Services Inc. (NMS). The Match places applicants into positions for the first year of accredited postdoctoral training in Oral and Maxillofacial Surgery, Orthodontics, Pediatric Dentistry, General Practice Residency, Advanced Education in General Dentistry and Dental Anesthesiology.
According to the data from NMS, 1721 of 1974 positions offered were filled in the Match, which is the highest fill rate in any of the last 15 years. The number of applicants participating in the Match increased by 3.3% to its highest level in Match history. According to Elliott Peranson, President of NMS, “the high level of applicant participation is being driven by the interest of current graduates of U.S. Dental schools to pursue advanced education.”
The Match uses the Roth-Peranson algorithm, which aligns the preferences of applicants and residency programs to generate an optimal result. The algorithm was designed by NMS and Stanford professor Alvin Roth, and was recognized in the awarding of Roth’s 2012 Nobel Prize in Economic Studies.
The algorithm acts as a central clearinghouse for all offers, acceptances and rejections. By centralizing the offer-acceptance process, both applicants and recruiters can be confident that they will receive the most preferred placement available to them. It creates a fair and efficient recruitment process that eliminates many of the common adverse situations found in competitive recruitment environments, like applicants hoarding offers and recruiters overfilling positions.
“We are very proud to be the trusted provider of matching services to the dental profession,” said Elliott Peranson. “By working closely with the sponsoring organizations of the Match, we have developed a Matching Program that leverages the power of the Roth-Peranson algorithm while fitting the unique needs of the postdoctoral dental residency recruitment environment.”
The Match to fill postdoctoral positions in dentistry has operated successfully since 1985 and has expanded to include six dental specialties. The Match is sponsored jointly by the American Association of Oral and Maxillofacial Surgeons, the Special Care Dentistry Association Council of Hospital Dentistry, the American Academy of Pediatric Dentistry, the American Association of Orthodontists, the American Society of Dentist Anesthesiologists and the American Student Dental Association. In addition, the Match has been endorsed by the American Dental Association Council on Dental Education and Licensure, the American Dental Education Association, and the Veterans Administration
About National Matching Services:
National Matching Services is the leading outsourced provider of matching services to professional organizations and industry associations. Since 1985, NMS has designed and implemented Matching Programs for competitive recruitment in a variety of industries, including health, education and law. NMS Matching Programs take the stress out of recruitment by providing tools for sponsoring organizations to oversee the recruitment process and giving applicants and recruiters confidence that they will obtain the best possible placement. National Matching Services is headquartered in Toronto, Ontario."
Wednesday, January 29, 2014
Cash for kidneys: letters to the editor of the WSJ
The recent Becker-Elias article, about which I blogged about my thoughts here, has drawn some letters to the editor, which the WSJ published under the headline Is a Market in Kidneys the Right Answer to Shortage? It is a tragedy when people die while waiting for a lifesaving transplant, but paying for organs isn't the answer.
One of them, by Sigrid Fry-Revere, doesn't fit the sub-headline. She advocates adopting something like the market approach in Iran. Her unedited letter, which she shared by email, is below:
One of them, by Sigrid Fry-Revere, doesn't fit the sub-headline. She advocates adopting something like the market approach in Iran. Her unedited letter, which she shared by email, is below:
Letter
to the Editor of WSJ
Edited
version ran Sat. Jan 2014
The
Rest of the Story
I
read with great interest Gary S. Becker and Julio Elias article “Cash for
Kidneys: The Case for a Market for Organs” in Saturday’s WSJ. Like so
many others who have written on this subject, their article misrepresents the
Iranian system of compensated donation.
Usually
not much is said about Iran, because not much is known, but I went to Iran and
spent nearly two months interviewing paid kidney donors for a documentary film
I was planning. I visited six different regions and returned with over 200
transplant stories. There are too many misconceptions about what is going
on in Iran to explain in one letter, but the most important thing I would like
to point out is that paid kidney donors are people, not commodities, and no
matter what the economics of the situation, there is a human element that can’t
be ignored.
You
might think I’m going to say we should not pay kidney donors, or that I’m going
to rage about how exploitive kidney selling is. Not so. I learned many things
on my trip to Iran, but the most important was sometimes money is what makes
helping others possible.
The
issue isn’t how much a kidney is worth, but how to make helping economically
feasible and how best to show appreciation. I disagree with economists who say
you can put value on someone giving up part of their body to save another
person’s life. A conscious, informed decision, to risk oneself for another is
an invaluable gift both to the person and to society.
Iran
is the only country in the world that has solved its kidney shortage, and it
has done so by legalizing and regulating compensated donation. In the
rest of the world there are two options: Altruistic donation and the
black market. The third option only exists in Iran where the rule of law
protects donors and recipients alike. Paid donors are not treated like
criminals, as is the case when the underprivileged are exploited for their
kidneys on the black market.
The
Iranian system has developed over 30 years and continues to improve.
Today, paid donors are secure in their knowledge that the system works to
protect their rights as much as the rights of recipients. Their money is put in
escrow, the middlemen who arrange kidney matches are NGO volunteers, not black
market profiteers, and they are treated on the same medical wards and in the
same post-operative clinics as kidney recipients.
How
much are Iranian kidney donors paid for their service to humanity? Much more
than the thank you, travel expenses, and occasional lost wages, paid altruistic
donors in the United States. Iranian kidney donors receive the equivalent to
six month’s salary for a registered nurse in Iran, or approximately $32,000 in the
United States. But in addition to monetary compensation, they receive many
goods and services that are hard to quantify in dollars. All receive at
least one year of health insurance, not just care related to their nephrectomy,
as is the case in the United States. They also receive automatic exemption from
Iran’s two-year mandatory military service.
Furthermore,
Kidney donors often receive extra health insurance, sometimes for their whole
family and often under terms where it can be renewed annually. They receive
dental care at the NGO dental clinics that serve diabetes patients and kidney
recipients. They receive job services, small business loans, and household
goods. I estimate the total average package paid donors receive in Iran
is close to $45,000 in value.
Most
importantly, these paid donors know the government supports them for having
done something honorable, like a paid firefighter or a paid emergency medical
professional. They have saved a life -- and their contribution to society is
invaluable. Mohaghegh Damad, the ethicist for the Iranian Academy of
Medical Sciences told me no payment could ever be enough. But, the payment
Iranian kidney donors get, makes doing the right thing easier.
In
the United States 20-30 people die every day because they can’t get a kidney.
Iran is the only country in the world where almost everyone who medically
qualifies to get a kidney gets one, and in many regions of the country there is
a waiting list for people who want to donate. Maybe its time we learn
something from their experience.
Sigrid
Fry-Revere, J.D., PhD, is a bioethicist and founder and president of the
non-profit organization Stop Organ Trafficking Now and author of The Kidney
Sellers (Carolina Academic Press, 2014).
Tuesday, January 28, 2014
More on unpaid internships and repugnance
Over at the Chronicle, the issue seems clear to journalism student Peter D'Amato: The Unpaid Internship Is Indefensible
And he's not alone, he reproduces this image:
My previous post on Should unpaid internships be repugnant drew some interesting comments...
And he's not alone, he reproduces this image:
My previous post on Should unpaid internships be repugnant drew some interesting comments...
Monday, January 27, 2014
New transplant statistics from Israel
The Jerusalem Post has the story: Israel Transplant Center reaches all-time high in number of transplants, potential donors
"Last year brought good news to the Israel Transplant Center and to 392 people whose lives were saved by deceased and live donors.
There was an increase by 24 percent of live kidney donors; 56% of family members of deceased agreed to donate organs; 90,000 more people signed donor cards; and almost half of those who received organs from deceased donors were advanced in the queue because they had signed a donor card.
In addition, the first transplant of a small intestine was successfully performed and 637 corneas were also transplanted in 769 patients (some were split into parts), giving recipients the gift of sight, the center announced on Sunday.
Of the 143 requests to families whose loved ones suffered lower-brain death, 80 of them consented to give one or more organs. The families said it was important to save the lives of others, while the most common reason for refusal were “religious” – even though modern Orthodox clergymen say donating fulfills a very important positive commandment – and the concern that the body to be buried would “not be whole.”
The figure of 392 donated organs was the highest ever.
Of these, 104 of the donors were from live relatives (who gave a kidney or liver lobe), and the rest were from altruistic families who gave their loves ones’ organs.
Of 248 organs from deceased donors, 109 of the recipients had to wait less because they had previously signed up as potential donors. The number of patients waiting to receive a lifesaving organ dropped from 1,114 in 2012 to 1,075 in 2013.
Of the 109 recipients who were advanced in the queue, four received hearts, 25 received lungs, 13 received livers and 67 received kidneys.
Of the deceased donors, 112 were donors of kidneys, 10 of kidney-pancreases, 5 double kidneys (usually from elderly donors), 57 of livers, one liver and kidney, 13 hearts, 24 double lungs, 25 single lungs and one “domino” donation of a liver (when an organ or part of one is removed for the primary purpose of a person’s medical treatment and may prove suitable for transplant into another person)."
HT: Jay Lavee
"Last year brought good news to the Israel Transplant Center and to 392 people whose lives were saved by deceased and live donors.
There was an increase by 24 percent of live kidney donors; 56% of family members of deceased agreed to donate organs; 90,000 more people signed donor cards; and almost half of those who received organs from deceased donors were advanced in the queue because they had signed a donor card.
In addition, the first transplant of a small intestine was successfully performed and 637 corneas were also transplanted in 769 patients (some were split into parts), giving recipients the gift of sight, the center announced on Sunday.
Of the 143 requests to families whose loved ones suffered lower-brain death, 80 of them consented to give one or more organs. The families said it was important to save the lives of others, while the most common reason for refusal were “religious” – even though modern Orthodox clergymen say donating fulfills a very important positive commandment – and the concern that the body to be buried would “not be whole.”
The figure of 392 donated organs was the highest ever.
Of these, 104 of the donors were from live relatives (who gave a kidney or liver lobe), and the rest were from altruistic families who gave their loves ones’ organs.
Of 248 organs from deceased donors, 109 of the recipients had to wait less because they had previously signed up as potential donors. The number of patients waiting to receive a lifesaving organ dropped from 1,114 in 2012 to 1,075 in 2013.
Of the 109 recipients who were advanced in the queue, four received hearts, 25 received lungs, 13 received livers and 67 received kidneys.
Of the deceased donors, 112 were donors of kidneys, 10 of kidney-pancreases, 5 double kidneys (usually from elderly donors), 57 of livers, one liver and kidney, 13 hearts, 24 double lungs, 25 single lungs and one “domino” donation of a liver (when an organ or part of one is removed for the primary purpose of a person’s medical treatment and may prove suitable for transplant into another person)."
HT: Jay Lavee
Sunday, January 26, 2014
The Financial Times on looking into the future "In 100 Years"
Simon Kuper at the FT reviews the recent book of essays ‘In 100 Years: Leading Economists Predict the Future’, by Ignacio Palacios-Huerta (ed), MIT Press
The economist’s guide to the future
Prediction is hard, but so is summary. About my essay, he writes
Roth foresees parents manipulating their children’s genes. Some such methods, he writes, “may come to be seen as part of careful child rearing”. He also thinks people will become more efficient thanks to performance-enhancing drugs that improve “concentration, memory, or intelligence”.
Once humans have more years in good health, they will probably reorder their lives. Roth says that if child rearing takes up less of the lifespan, people may want different spouses for different phases of life. “New forms of polygamy-over-lifetime relationships” could arise, he writes.
The economist’s guide to the future
Prediction is hard, but so is summary. About my essay, he writes
Roth foresees parents manipulating their children’s genes. Some such methods, he writes, “may come to be seen as part of careful child rearing”. He also thinks people will become more efficient thanks to performance-enhancing drugs that improve “concentration, memory, or intelligence”.
Once humans have more years in good health, they will probably reorder their lives. Roth says that if child rearing takes up less of the lifespan, people may want different spouses for different phases of life. “New forms of polygamy-over-lifetime relationships” could arise, he writes.
You can see a longer summary and a link to the full essay here.
And here's the book on Amazon:‘In 100 Years: Leading Economists Predict the Future’
Saturday, January 25, 2014
Brookings Education Choice and Competition Index 2013
The Education Choice and Competition Index Background and Results 2013
| Rank | School District | Grade | County |  Student Population | No. of Schools | |
|---|---|---|---|---|---|---|
| 1 | Recovery District | A | Orleans Parish, LA | 47,493 | 126 | |
| 2 | New York City | A- | New York County, NY | 1,150,795 | 2,431 | |
| 3 | Orleans Parish | A- | Orleans Parish, LA | 51,042 | 119 | |
| 4 | Houston | B | Harris County, TX | 220,754 | 471 | |
| 5 | Denver | B | Denver County, CO | 87,147 | 229 | |
| 6 | Minneapolis | B | Hennepin County, MN | 46,165 | 122 | |
| 7 | Washington DC | B- | District Of Columbia, DC | 72,875 | 295 | |
| 8 | San Diego | B- | San Diego County, CA | 146,207 | 309 | |
| 9 | Tucson | B- | Pima County, AZ | 66,505 | 215 | |
| 9 | Chicago | B- | Cook County, IL | 427,945 | 961 | |
Executive summary:
"The United States is in the middle of a K-12 education revolution that is characterized by many dramatic transformations — among them, a shift toward more choice by parents in where their children are educated with public funds. This shift is signified by, among other things, the growth of public charter schools, the adoption of open enrollment systems for public schools, the expansion of statewide voucher programs, and continued increases in the availability of technology-based distance/virtual education.
"Although the expansion of choice in education is driven by a widely-recognized market model, which posits that allowing students and their families to choose schools and backpack their public funds will force education service providers to innovate and compete on the quality of their product, there is little available information about the current state of school choice in American education. For that reason, the Brown Center on Education Policy at Brookings compiles an annual Education Choice and Competition Index (ECCI) of 100+ U.S. school districts. The ECCI is based on scoring rubrics within thirteen categories of policy and practice that are important to the availability and quality of choice and to the competition created by choice among providers of education services.
"Based on these scoring principles, the Recovery School District in New Orleans and New York City Public Schools occupy the highest rankings on the 2013 ECCI, with scores of 83 and 73 points out of 100, respectively. Both districts occupied those same rankings in 2012, illustrating a larger trend uncovered by the ECCI: districts demonstrate little year-to-year change in their commitment to or design of school choice. The correlation between this year’s and last year’s aggregate district scores is 0.95. There are, however, exceptions. Denver dramatically improved its ranking, moving from 24th to fifth place, based on its implementation of a unified application process for all its public schools, including charters.
"Despite their high rankings, the Recovery School District and New York City, along with all other top-scoring districts, need improvements. And, as demonstrated by the 34 districts that received an “F” grade, zip code assignment and other policies antithetical to choice still represent standard operating procedure for many school districts across the country."
Friday, January 24, 2014
Scholarships for donors and donor family members
The Isabelle Christenson Memorial Scholarship honors the life of a brave transplant recipient who died when she was only 10 years old. It is a scholarship available to anyone connected to a donor or transplant recipient:
"Scholarship Requirements: Be an organ transplant candidate, recipient, donor family member, living donor or immediate family member of a transplant candidate or recipient "
HT: Sangram Kadam
"Scholarship Requirements: Be an organ transplant candidate, recipient, donor family member, living donor or immediate family member of a transplant candidate or recipient "
HT: Sangram Kadam
Thursday, January 23, 2014
Venture capital looks at the design of marketplaces
Not long ago I had a chance to listen to some interesting presentations at a conference sponsored by Greylock Partners, about businesses that aim to make marketplaces: As Marketplaces Evolve, Greylock Places Its Bets
Leena Rao writes:
"The idea of marketplaces as a business model for technology startups isn’t new. We saw some marketplaces go belly up in the bubble, and saw a few, like eBay, grow into massive businesses. However, the marketplace model has experienced a renaissance of sorts lately, with companies like Airbnb, Uber and others gaining serious traction and becoming billion-dollar-plus businesses.
Leena Rao writes:
"The idea of marketplaces as a business model for technology startups isn’t new. We saw some marketplaces go belly up in the bubble, and saw a few, like eBay, grow into massive businesses. However, the marketplace model has experienced a renaissance of sorts lately, with companies like Airbnb, Uber and others gaining serious traction and becoming billion-dollar-plus businesses.
Greylock Partners held a conference in mid-November devoted to talking about design, product development, the economics and more around marketplaces, spearheaded in part by the firm’s newest partner and former eBay Motors creator, Simon Rothman.
As part of its new $100 million commitment to investing in marketplaces, Greylock assembled Reid Hoffman, Airbnb co-founder and CEO Brian Chesky, eBay CEOJohn Donahoe, Nobel Prize Laureate and marketplace expert Alvin Roth, and many others to discuss the rise of marketplaces and much more. I was able to sit down with some of the speakers to talk about their thoughts on why marketplaces are hot right now.
Hoffman, who founded LinkedIn and was an early investor in Facebook, sees many parallels between networks and marketplaces. On the similarities in both models, he says: “There’s a question of how do you identify people? What reputational systems underlie it? What kinds of information and signaling? What kind of transactions go public? There’s some differences, too, but it’s essentially a similar brain activity.”
As for why marketplaces are getting more attention now, Hoffman believes that it’s in part due to mobile and the progression in human behavior. “Now everyone is comfortable with the notion of, ‘Oh, I could actually find someone I don’t know and transact with them, either as travelers, hosts, sellers, buyer.’ Those that can actually work mean that I have some trust in these mechanisms,” he explains further.
Rothman agrees with Hoffman, and told me that trust is a huge element of why marketplaces have evolved, as well as the biggest challenge for these marketplaces. “They’re really selling trust. And until the web adds social identity, I think creating trust at scale is really hard. As we’ve heard, marketplace is about influence, and if you can’t control the experience, if you can’t control the product, you can’t control the fulfillment. All you can control is trust and you need to have that. And then mobile is an accelerant to that. If you are a local market, or a local business, you have to have mobile. There’s just no way Uber works without mobile,” he says.
...
So how do marketplaces add trust? Hoffman advises to look at mechanisms by which you can essentially borrow some trust and add it to the product, such as using social networks or identities. He recalled a product development from his PayPal days, where an engineer developed a better way to authenticate bank accounts.
For years, in order to authenticate a bank account you had to send in a voided check, and a copy of your drivers license. PayPal realized that if they wanted to get to scale, the company would have to make it easier to create accounts. “If we can’t solve this problem, we basically don’t have an interesting business model,” he said. One of the early engineers developed a way to send two sub-dollar transactions to the account, to create a PIN of sorts for instant verification.
While friction is something most marketplaces want to remove, Rothman argues that some should consider “the concept of strategic friction” when it comes to trust and safety. He thinks it’s one of the only places where friction is not only tolerable but kind of desirable.
...
"Hoffman says that Airbnb was creating liquidity out of space. Even if the hosts didn’t own their real estate, the liquidity involved is “hugely valuable and motivating to them.” So, they’ll adopt mobile products, and go through hoops to make that happen. “There was no question that this is going to work,” he says.
...
Now that Greylock is allocating some of its new $1 billion in funding toward the marketplace model, we’ll be looking to see where the firm will be placing its bets. Rothman thinks that in the next five years there will be more $1 billion dollar marketplaces than there were in the past 20 years, and we already have quite a few that are rising fast. Stay tuned."
Wednesday, January 22, 2014
Webcast of the luncheon talks on market design from the 2014 AEA Annual Meeting
The AEA has posted a collection of webcasts from the 2014 annual meeting in Philadelphia, including from the
Nobel Laureate Luncheon
William Nordhaus; Paul Milgrom; Roger Myerson
View Webcast
The video is a little less than an hour: and consists of brief introductions by Nordhaus, and talks on market design and its history by Milgrom and Myerson, and a short talk by me with some thoughts on the future of market design as economic engineering and the science that supports it. (spoiler: I think it will be important to study congestion...)
**************
Nobel Laureate Luncheon
William Nordhaus; Paul Milgrom; Roger Myerson
View Webcast
The video is a little less than an hour: and consists of brief introductions by Nordhaus, and talks on market design and its history by Milgrom and Myerson, and a short talk by me with some thoughts on the future of market design as economic engineering and the science that supports it. (spoiler: I think it will be important to study congestion...)
**************
Eleven 2014 Annual Meeting sessions are
available online. (I enjoyed Claudia Goldin's magisterial address on gender and jobs, which reminded me of the work following up on this and the matching aspects of pursuing both careers and marriages, of our joint student Stephanie Hurder.):
- AEA Presidential Address "A Grand Gender Convergence: Its Last Chapter" (Claudia Goldin)
- AEA Awards Ceremony (William
Nordhaus)
- Richard T. Ely Lecture
"Retirement Security in an Aging Population" (James Poterba)
- Nobel Laureate Luncheon (Paul
Milgrom, Roger Myerson, and Alvin Roth)
- AEA/AFA Joint Luncheon (Jeremy Stein)
- Chairman Bernanke Presentation (Ben
Bernanke, Kenneth Rogoff, and Anil Kashyap)
- What's Natural? Key Macroeconomic
Parameters after the Great Recession
- Discounting for the Long Run
- Financial Globalization
- Climate Change Policy after Kyoto
- Macroeconomics of Austerity
Tuesday, January 21, 2014
Scalper resistant Super Bowl tickets
Assaf Romm points me to the story: Take that, Super Bowl scalpers! Ticket-lottery winners to get non-transferable tickets
"Every year, the NFL holds a lottery for football fans for the next
year’s Championship. Some 30,000 people entered this year, McCarthy said. The
number of winners will double to 1,000, McCarthy said, and the price of the
ticket will drop to $500, from last year’s $600.
But there’s a catch. Winners won’t get their tickets until game
day, and they won’t be able to leave the stadium after receiving them, McCarthy
said.
“The point is we want these people going to the game,” McCarthy
said. “So you can’t turn around and sell them to a scalper.”
Monday, January 20, 2014
Ricky Vohra's class in market design at Penn
Ricky Vohra is teaching market design at Penn, and describes it on his blog: Graduate Market Design Class (2nd Try)
Here's the reading list
Here's the reading list
Topics & Papers
1. IPOs
Jaganathan and Sherman: Why do IPO Auctions Fail
Ritter: Equilibrium in the IPO market
Background Reading (to be read by all)
Ljungqvist: IPO Underpricing: A Survey
Ritter and Welch: A review of IPO activity, pricing and allocations
Ljungqvist: IPO Underpricing: A Survey
Ritter and Welch: A review of IPO activity, pricing and allocations
2. Health Care & Insurance Markets
Cochran, J: Time Consistent Health Insurance, JPE 1995.
Cochran, J. : After the ACA: Freeing the market for health care
Fang & Gazzara: Dynamic Inefficiencies in an Employment-Based Health Insurance System: Theory and Evidence
Handel, Hendel and Whinston: Equilibria in Health Exchanges: Adverse Selection vs. Reclassification Risk
Levine, Kremer and Albright: Making Markets for Vaccines
Kremer: Creating Markets for New Vaccines Part 1: rationale
Kremer: Creating Markets for New Vaccines Part 2: design issues
Cochran, J. : After the ACA: Freeing the market for health care
Fang & Gazzara: Dynamic Inefficiencies in an Employment-Based Health Insurance System: Theory and Evidence
Handel, Hendel and Whinston: Equilibria in Health Exchanges: Adverse Selection vs. Reclassification Risk
Levine, Kremer and Albright: Making Markets for Vaccines
Kremer: Creating Markets for New Vaccines Part 1: rationale
Kremer: Creating Markets for New Vaccines Part 2: design issues
Background Reading (to be read by all)
Rothschild, M. & J. Stiglitz: Equilibrium in Competitive Insurance Markets, QJE 1976.
Fang, H: Insurance Markets in China
Rothschild, M. & J. Stiglitz: Equilibrium in Competitive Insurance Markets, QJE 1976.
Fang, H: Insurance Markets in China
3. Market for Cybersecurity Insurance
Kesan, Majuca & Yurcik: Cyberinsurance as a market based solution to the problem of cybersecurity
4. Affirmative Action
Hickman: Effort, Race Gaps and Affirmative Action: A Game Theoretic Analsyis of College Admissions
Chung: Affirmative Action as an Implementation Problem
Fryer and Loury: Valuing Identity: The simple economics of Affirmative action policies
Chung: Affirmative Action as an Implementation Problem
Fryer and Loury: Valuing Identity: The simple economics of Affirmative action policies
Background Reading (to be read by all)
Fang and Moro: Theories of Statistical Discrimination and Affirmative Action: a survey
Fang and Moro: Theories of Statistical Discrimination and Affirmative Action: a survey
5. Assigning Counsel
Friedman & Schulhofer: Rethinking Indigent Defense: Promoting Effective Representation Through Consumer Sovereignty and Freedom of Choice for All Criminal Defendants
6. The Role of Politics
Acemoglu: Why not a political Coase theorem?
Acemoglu: Modeling Inefficient Institutions
Acemoglu: Modeling Inefficient Institutions
Sunday, January 19, 2014
Cash for Kidneys: The Case for a Market for Organs. Becker and Elias in the WSJ
Gary Becker and Julio Elias have a reprise of their 2007 Journal of Economic Perspectives paper in this weekend's Wall Street Journal, in a cogent column called Cash for Kidneys: The Case for a Market for Organs.
Their 2007 JEP paper was called Introducing Incentives in the Market for Live and Cadaveric Organ Donations (slightly more direct link here).
Between then and now the number of people on the waiting list for kidneys has gone up. Their 2007 article has these sentences: "Almost 17,000 persons were waiting for a kidney transplant in 1990. But this number grew rapidly, so that about 65,000 persons were on this waiting list by the beginning of 2006."
This weekend's WSJ column starts with the sentence "In 2012, 95,000 American men, women and children were on the waiting list for new kidneys, the most commonly transplanted organ."
So, the arguments that they repeat have gotten stronger over time: the shortage of organs is costly in every sense, and could likely be relieved by allowing kidneys to be bought and sold by live donors, and allowing the purchase of organs from deceased potential donors, i.e. by repealing the part of the 1984 National Organ Transplant Act that makes such sales a felony in the United States. (Similar laws exist in most of the developed world: the only country that seems to have an explicitly legal market for kidneys is Iran, although many black and grey markets exist.)
So, why hasn't this argument made any headway, either in the U.S. or overseas? Is patient repetition of the argument the best way to make the case? I don't know the answers, but I think that the repugnance of organ sales is a subject worth studying, not just for science but also for those who might like to influence policy.
In the same issue of the JEP as Becker and Elias (2007) was my article Repugnance as a Constraint on Markets (more direct link here), which sought to understand not just the repugnance to kidney sales, but to many economic transactions, in different places and times, e.g. to charging interest on loans, or having markets for slaves or indentured servants. I noted that kidney exchange doesn't arouse the repugnance that sales do. I've since blogged about a lot of different repugnant transactions including compensation for donors (as of this writing my most recent post on transactions that some regard with repugnance is headlined Womb transplants in Sweden (where surrogacy is illegal)...)
Note that the prohibition on organ sales is not some law that remains on the books merely through inattention. This is illustrated by the recent events surrounding the tug of war over whether it might be legal to compensate (even) bone marrow donors. Briefly, the ninth circuit court of appeals issued a ruling that said that in some circumstances bone marrow donors could be compensated, but then the Department of Health and Human Services proposed regulations that would keep the ban in place. So the opposition to organ sales--even to compensating bone marrow donors--is alive and well.
But things don't go all in one direction. Bob Slonim reminds me that while we rely on unpaid donation of whole blood in the United States, most of our supply of blood plasma comes from paid donors.
I've participated in some efforts to understand better the repugnance to compensating organ donors, e.g. here's a survey with Steve Leider about who disapproves of kidney sales, and some correlates of such disapproval:
Leider, Stephen and Alvin E. Roth, ''Kidneys for sale: Who disapproves, and why? American Journal of Transplantation 10 (May), 2010, 1221-1227.
More recently, Muriel Niederle and I conducted a different sort of survey, which assessed the relative willingness of Americans to contemplate monetary rewards for the heroism associated with kidney donation:
"Niederle, Muriel and Alvin E. Roth, “Philanthropically Funded Heroism Awards for Kidney Donors?” forthcoming in Law & Contemporary Problems, 77:3, 2014.
Judd Kessler and I have a paper forthcoming in the American Economic Review papers and proceedings (May 2014) called "Getting More Organs for Transplantation," in which we summarize the issue this way:
"Kidney sales are often the leading example of a repugnant transaction cited by those who would put stricter limits on markets in general (e.g. Sandel 2012, 2013), because of their sense that such sales arouse widespread opposition. A representative sample survey of Americans conducted by Leider and Roth (2010) suggests that disapproval of kidney sales correlates with other socially conservative attitudes, but that it does not rise to the level of disapproval of other repugnant transactions such as prostitution. In addition, there is evidence that the manner of the payment to an organ donor may mitigate some of the repugnance concerns. Niederle and Roth (forthcoming 2014) find that payments to non-directed kidney donors are deemed more acceptable when they arise as a reward for heroism and public service than when they are viewed as a payment for kidneys."
That paper closes with this thought on the presently available options:
"While these potential donors could save thousands of additional lives, at current rates of medical need, these donors alone would not be able to supply all the demand. Consequently, we must continue working on numerous fronts to solve this growing problem. "
In summary, the issue of whether and how organ donors might be compensated is an important policy issue that also touches on an important and still poorly understood social science phenomenon. Repetition of the basic arguments may move the discussion forward as the background facts become more severe, and it's great to see the issue addressed in such a public forum as the WSJ. But it may also be that repetition of arguments is not enough. To make progress in the face of opposition, it seems likely to be useful to understand better the nature of the opposition.
Their 2007 JEP paper was called Introducing Incentives in the Market for Live and Cadaveric Organ Donations (slightly more direct link here).
Between then and now the number of people on the waiting list for kidneys has gone up. Their 2007 article has these sentences: "Almost 17,000 persons were waiting for a kidney transplant in 1990. But this number grew rapidly, so that about 65,000 persons were on this waiting list by the beginning of 2006."
This weekend's WSJ column starts with the sentence "In 2012, 95,000 American men, women and children were on the waiting list for new kidneys, the most commonly transplanted organ."
So, the arguments that they repeat have gotten stronger over time: the shortage of organs is costly in every sense, and could likely be relieved by allowing kidneys to be bought and sold by live donors, and allowing the purchase of organs from deceased potential donors, i.e. by repealing the part of the 1984 National Organ Transplant Act that makes such sales a felony in the United States. (Similar laws exist in most of the developed world: the only country that seems to have an explicitly legal market for kidneys is Iran, although many black and grey markets exist.)
So, why hasn't this argument made any headway, either in the U.S. or overseas? Is patient repetition of the argument the best way to make the case? I don't know the answers, but I think that the repugnance of organ sales is a subject worth studying, not just for science but also for those who might like to influence policy.
In the same issue of the JEP as Becker and Elias (2007) was my article Repugnance as a Constraint on Markets (more direct link here), which sought to understand not just the repugnance to kidney sales, but to many economic transactions, in different places and times, e.g. to charging interest on loans, or having markets for slaves or indentured servants. I noted that kidney exchange doesn't arouse the repugnance that sales do. I've since blogged about a lot of different repugnant transactions including compensation for donors (as of this writing my most recent post on transactions that some regard with repugnance is headlined Womb transplants in Sweden (where surrogacy is illegal)...)
Note that the prohibition on organ sales is not some law that remains on the books merely through inattention. This is illustrated by the recent events surrounding the tug of war over whether it might be legal to compensate (even) bone marrow donors. Briefly, the ninth circuit court of appeals issued a ruling that said that in some circumstances bone marrow donors could be compensated, but then the Department of Health and Human Services proposed regulations that would keep the ban in place. So the opposition to organ sales--even to compensating bone marrow donors--is alive and well.
But things don't go all in one direction. Bob Slonim reminds me that while we rely on unpaid donation of whole blood in the United States, most of our supply of blood plasma comes from paid donors.
I've participated in some efforts to understand better the repugnance to compensating organ donors, e.g. here's a survey with Steve Leider about who disapproves of kidney sales, and some correlates of such disapproval:
Leider, Stephen and Alvin E. Roth, ''Kidneys for sale: Who disapproves, and why? American Journal of Transplantation 10 (May), 2010, 1221-1227.
More recently, Muriel Niederle and I conducted a different sort of survey, which assessed the relative willingness of Americans to contemplate monetary rewards for the heroism associated with kidney donation:
"Niederle, Muriel and Alvin E. Roth, “Philanthropically Funded Heroism Awards for Kidney Donors?” forthcoming in Law & Contemporary Problems, 77:3, 2014.
Judd Kessler and I have a paper forthcoming in the American Economic Review papers and proceedings (May 2014) called "Getting More Organs for Transplantation," in which we summarize the issue this way:
"Kidney sales are often the leading example of a repugnant transaction cited by those who would put stricter limits on markets in general (e.g. Sandel 2012, 2013), because of their sense that such sales arouse widespread opposition. A representative sample survey of Americans conducted by Leider and Roth (2010) suggests that disapproval of kidney sales correlates with other socially conservative attitudes, but that it does not rise to the level of disapproval of other repugnant transactions such as prostitution. In addition, there is evidence that the manner of the payment to an organ donor may mitigate some of the repugnance concerns. Niederle and Roth (forthcoming 2014) find that payments to non-directed kidney donors are deemed more acceptable when they arise as a reward for heroism and public service than when they are viewed as a payment for kidneys."
That paper closes with this thought on the presently available options:
"While these potential donors could save thousands of additional lives, at current rates of medical need, these donors alone would not be able to supply all the demand. Consequently, we must continue working on numerous fronts to solve this growing problem. "
In summary, the issue of whether and how organ donors might be compensated is an important policy issue that also touches on an important and still poorly understood social science phenomenon. Repetition of the basic arguments may move the discussion forward as the background facts become more severe, and it's great to see the issue addressed in such a public forum as the WSJ. But it may also be that repetition of arguments is not enough. To make progress in the face of opposition, it seems likely to be useful to understand better the nature of the opposition.
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