The Marshall Lectures at Cambridge, Feb 19-20

THE MARSHALL LECTURES for 2013-2014

Professor Alvin Roth (Stanford and Harvard University) will deliver two lectures on "Matching Markets and Market Design" in the Lady Mitchell Hall at 5 pm on Wednesday 19 February and Thursday 20 February A question and answer session will follow the second lecture All Welcome Suggested Readings Roth, Alvin E., "The Economist as Engineer: Game Theory, Experimentation, and Computation as Tools for Design Economics", Fisher-Schultz Lecture, Econometrica, 70,4, July 2002, 1341-1378. Roth, Alvin E. "What have we learned from market design?" Hahn Lecture, Economic Journal, 118 (March), 2008, 285-310. Roth, Alvin E. "What have we learned from market design? Update to Roth (2008)", September, 2010 in El Trimestre Economico.

The Financial Times excerpts "In 100 Years"

I've blogged before about the book of essays edited by Ignacio Palcios-Huerta, "In 100 Years..."  Now the Financial Times has published short excerpts of three of the essays, by Marty Weitzman, me, and Bob Shiller. Below are excerpts of the excerpts...

Forecast: The world in 2114
Economists predict that geo-engineering, performance drugs and artificial intelligence will shape our future

Martin Weitzman

If there is one natural bridge spanning the chasm between today and a century from now, it is climate change. We can envision only the foundation of this bridge. Even so, we can make out enough features to sense that something big and possibly ominous may be on the distant horizon.

• Alvin Roth

The biggest trend of future history is that the world economy will keep growing and becoming more connected. Material prosperity will increase and healthy longevity will rise. While greater prosperity will not eliminate competition, it will give people more choices about whether and how hard to compete. Many will opt for a slower track, spending more time accumulating youthful experiences. Retirement will be a longer part of life and new forms of retirement will emerge.

For those who wish to compete, there will be technological developments to help them. Some of these, such as performance-enhancing drugs, are becoming available today but are widely regarded as repugnant. That repugnance seems likely to fade.

• Robert Shiller

The next century carries with it any number of risks as an unprecedented number of people attempt to live well on a planet with limited resources, with more dangerous strategic weapons of mass destruction, and with the flourishing of new information technologies that stir up labour markets and create career risks.

Much of the management of these risks will be in the domain of science and engineering but there is also the purely financial and insurance domain. There is an expectation that with the help of new technology, far better risk management will be deployed against all these risks.

University of Cologne is advertising for market designers

The Faculty of Management, Economics and Social Sciences at the University of Cologne seeks to appoint one full Professor (W3), and one assistant Professor with tenure track (W1), in Economics: Behavior & Design

The positions are created as a result of the University's successful application in the excellence initiative of the German government, and will be integrated into the University’s key profile area “Behavioral Economic Engineering and Social Cognition”.
In recent years, the University of Cologne has built up expertise both in Behavioral and Experimental Economics as well as in Social Cognition. In parallel to these two positions in economics, the University of Cologne is hiring two new professors in psychology (social and economic cognition). The successful candidates are expected to contribute to the further expansion of this research area.

For the present positions, we seek candidates with an economics or related background, a research focus in behavioral and experimental economics, design economics, or related fields, and an interest to connect to social cognition research. Successful candidates will have demonstrated excellence in research as well as teaching.

Salaries are based on the German W-scheme, with supplementary allowances competitive with international salaries, contingent on academic achievements and teaching experience. There is no teaching load initially, but some teaching is welcome.Candidates are expected to be willing to learn the German language.

The University of Cologne is one of Germany’s largest universities. The Faculties offer B.A., M.A. and doctoral degrees. Courses are taught either in English or German.
The University of Cologne is an equal opportunity employer in compliance with the German disability laws. Women and persons with disabilities are therefore strongly encouraged to apply.

Please submit your electronic application including the typical materials (vita, list of publica-tions and teaching experiences, diplomas) no later than 30th October 2012 to the dean of the Faculty of Management, Economics and Social Sciences of the University of Cologne, Albertus-Magnus-Platz, 50932 Cologne, Germany. E-Mail: bewerbung@wiso.uni-koeln.de.

All application materials shall be submitted as one document in PDF or MSWord-format. Ac-knowledgments of receipt will be sent out within one week.
For further information please contact Axel Ockenfels (ockenfels@uni-koeln.de) or Thomas Mussweiler (thomas.mussweiler@uni-koeln.de).

www.uni-koeln.de

Ben Edelman, Internet Sheriff

Bloomberg has a long story on Ben Edelman, as he might look to an internet badguy..

Harvard Professor Attacking Google Thrives as Web Sheriff
By John Hechinger  Feb 13, 2014 9:01 PM PT.

Give yourself a treat and read the whole thing. Here are the opening paragraphs:

"Benjamin Edelman knew his way around the Internet’s ethical thickets at an early age. He also knew how to make that knowledge pay.

"As a 19-year-old Harvard sophomore, he earned $400 an hour as an expert witness for the National Football League against unauthorized Web broadcasting. By his senior year, the American Civil Liberties Union enlisted him, at $300 an hour, to oppose the government’s use of information filters in libraries.

"Now on the faculty of Harvard Business School, Edelman epitomizes a new breed of sleuths for hire, enforcing norms of online behavior.

"Edelman is “an astonishing scholar of the Internet,” said Alvin Roth, a Nobel-prize winning economist, who was a mentor and colleague at Harvard Business School. “It’s the Wild West out there, and Ben is the sheriff.”

"Edelman, a 33-year-old associate professor, mixes scholarship, lucrative consulting and a digital version of the 1960s-style activism of his family, including his aunt, Marian Wright Edelman, the civil-rights and children’s advocate. While he ferrets out misdeeds on the Internet, his multiple roles have put his own work under scrutiny.

“The Internet is what we make of it,” said Edelman, who arrived at his Ivy League office in jeans and sneakers this week after commuting by bicycle through Boston’s snowy streets. “We can shape it through diligence, by exposing the folks who are making it less good than it ought to be, like the neighborhood watch, or the busybody neighbor who yells at you when you throw your cigarette butt on the street."

Is blogging repugnant?

Maybe blogging should be repugnant (especially when you're jetlagged in Chicago...)

Inside Higher Ed has the (unlikely) pair of stories:

Is Blogging Unscholarly? January 29, 2014 By Carl Straumsheim

"The political science blogosphere has erupted in protest after the International Studies Association unveiled a proposal to bar members affiliated with its scholarly journal from doing just that -- blogging.

“No editor of any ISA journal or member of any editorial team of an ISA journal can create or actively manage a blog unless it is an official blog of the editor’s journal or the editorial team’s journal,” the proposal reads. “This policy requires that all editors and members of editorial teams to apply this aspect of the Code of Conduct to their ISA journal commitments. All editorial members, both the Editor in Chief(s) and the board of editors/editorial teams, should maintain a complete separation of their journal responsibilities and their blog associations.”

"The Governing Council of the ISA, which consists of about 50 voting members, will debate the proposal the day before the association’s annual meeting in Toronto on March 25. Should the council adopt the proposal, it would impact five journals: International Studies Quarterly, International Studies Review, International Studies Perspectives, Foreign Policy Analysis and International Political Sociology, as well as International Interactions, which the association co-sponsors. "
**********
International Studies Association Tables Blogging Policy, January 30, 2014

"After a surge of protest from its members, the International Studies Association announced Wednesday afternoon that it would table a proposal to ban its journal editors from blogging. 
Harvey Starr, the association's president, said in an email to the Governing Council of the ISA that he intends to task the Committee on Professional Rights and Responsibilities to explore the "idea of balancing academic freedom and potential conflicts of interests" that blogging present. The committee will spend a year gathering input before making any recommendations at the 2015 annual meeting. "

Approaches to alleviating the shortage of transplant organs: AAAS annual meeting

Weather permitting, I'll be on my way to Chicago today for a session at the AAAS meeting, on the shortage of organs for transplants.

Transplant Organ Shortage: Informing National Policies using Management Sciences

Friday, 14 February 2014: 10:00 AM-11:30 AM

Columbus IJ (Hyatt Regency Chicago)

Since the first successful kidney transplant in 1954, outcomes have improved dramatically.  As a result,  the wait list for organ transplants has grown significantly over time. With only about 17,000  kidneys available from combined living and deceased donors annually, there are currently 99,000 Americans waiting for a kidney transplant, and the wait-list mortality is now higher than ever before. National policies for organ allocation are largely dictated by legislative priorities, but the organ shortage results in a number of disparities and therefore,  there is a growing interest in optimizing organ allocation policies to develop a balance between fairness, utility and efficiency.

Organs are a limited, perishable resource and using them more effectively saves more lives. The speakers in this briefing have taken an inter-disciplinary approach to addressing the organ allocation in the U.S., suggesting compelling and provocative solutions. Michael Abecassis, a transplant surgeon and Chief of the Transplant Program at Northwestern University’s Feinberg School of Medicine, and Past President of the American Society of Transplant Surgeons will offer a brief overview of the current issues facing organ allocation. John Friedewald, a transplant nephrologist and  Past Chair of the United Network for Organ Sharing Kidney and Pancreas Committee, that oversaw the most recent proposed changes in kidney allocation, also from Northwestern University’s Feinberg School of Medicine, will speak about the implications of these recent proposed changes to deceased donor kidney allocation policy. Nobel laureate (2012) and Stanford University economist Alvin Roth will discuss the evolution of innovative solutions to the organ shortage and how mathematical models are used to optimize Kidney Paired Donation and the impact of increasing living donor kidney transplants on the waiting list for deceased donor transplants. Sanjay Mehrotra from the McCormick School of Engineering at Northwestern University will discuss how simulation models can be used to optimize deceased donor kidney utilization to maximize utility.  Mark Siegler Director of the University of Chicago’s MacLean Center for Clinical Medical Ethics and executive director of the Bucksbaum Institute for Clinical Excellence will  will challenge some long-held beliefs about living donors and will address the salient issues related to ethical considerations in potential solutions to the organ shortage..

Michael Abecassis MD MBA, J. Roscoe Miller Distinguished Professor of Surgery and Microbiology/Immunology, Chief, Division of Transplantaiton, and Founding Director, Comprehensive Transplant Center Northwestern University Feinberg School of Medicine

Organizer

John Friedewald MD, Associate Professor of Medicine and Surgery, Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, and former chair, Organ Procurement and Transplantation Network/United Network for Organ Sharing Kidney Transplantation Committee

Discussant

Sanjay Mehrotra PhD, Professor, Department of Industrial Engineering and Management Sciences, Northwestern University McCormick School of Engineering, and Director, Center for Engineering and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine

Addressing Allocation Inefficiencies and Geographic Disparities

Alvin Roth PhD, Craig and Susan McCaw Professor of Economics, Stanford University, and co-recipient of the 2012 Nobel Prize in Economic Sciences

Allocating Donor Organs in Ways that Increase Their Availability

Mark Siegler MD, Lindy Bergman Distinguished Service Professor of Medicine and Surgery, University of Chicago Medicine, Founding Director of the MacLean Center for Clinical Medical Ethics and Executive Director of the Bucksbaum Institute for Clinical Excellence

Ethical Considerations for Innovative Strategies to Increase the Supply of Organs
*******************
Update: here's a picture of the panel:

and here's a news story: Math saving lives: New models help address kidney organ donation shortages

Payday loans versus bank overdraft charges

I've blogged before about very-high-interest-rate payday loans to "unbanked" customers, and the repugnance with which they are regarded in many quarters (in England and in Los Angeles).

Interestingly, the first and third of those posts have attracted a lot of comments, a few from serious people, but many from payday loan shops whose style makes it clear that they may verge on the fraudulent.

So it's interesting to note this recent blog post over at The Volokh Conspiracy:

Payday Lending and Overdraft Protection

by Todd Zywicki on January 17, 2014 5:18 pm

"I’ve noted previously, I have a forthcoming paper with former Comptroller of the Currency Robert Clarke that examines competition between payday lending and bank overdraft protection. The central point is easy to grasp–payday lending and overdraft protection are products offered by different providers but which compete for the same customers. And evidence indicates that in choosing between the two products consumers generally choose rationally.

The point came to mind (yet again) reading the Wall Street Journal yesterday, “Hefty Bank Fees Waylay Soldiers.” According to the article, many members of the military are frequent users of bank overdraft protection, which has caused some concern in some quarters. The article provides no hard evidence that usage of overdraft protection has risen in recent years, but implies that the general impression is that it has."

...

"as we note in the article, in many situations payday loans are less expensive than overdraft protection (it appears from the article that the break even point in favor of overdraft protection is lower than for payday loans because overdraft fees on military bases are lower than typical market rates) and consumers understand this and use the products rationally."

Do high earners marry each other?

Here's a paper that finds that they do:

Marry Your Like: Assortative Mating and Income Inequality

Jeremy Greenwood, Nezih Guner, Georgi Kocharkov, Cezar Santos

NBER Working Paper No. 19829
Issued in January 2014
NBER Program(s):   EFG 

Has there been an increase in positive assortative mating? Does assortative mating contribute to household income inequality? Data from the United States Census Bureau suggests there has been a rise in assortative mating. Additionally, assortative mating affects household income inequality. In particular, if matching in 2005 between husbands and wives had been random, instead of the pattern observed in the data, then the Gini coefficient would have fallen from the observed 0.43 to 0.34, so that income inequality would be smaller. Thus, assortative mating is important for income inequality. The high level of married female labor-force participation in 2005 is important for this result.

Kidney exchange in San Antonio

Here's a news release from San Antonio, where Adam Bingaman is doing great things in kidney exchange:

SAN ANTONIO, Texas, Feb. 10, 2014/NEWS.GNOM.ES/ — Methodist Specialty and Transplant Hospital (MSTH), a campus of Methodist Hospital,  has performed its 250th  paired kidney exchange, setting a national record for a single hospital, while performing 10 lifesaving exchange transplants during the last week of January.

...

“Our philosophy is to help as many people as we can despite the challenges,” said Adam Bingaman, M.D., Ph.D., transplant surgeon and director of the program. “There are over 95,000 people on the kidney transplant waiting list and their chances of receiving a transplant are low, with an average wait of more than five years. Time is against people on dialysis – the sooner we can get them transplanted, the sooner they can return to good health.” Each year about 4,500 Americans die waiting for a kidney.

"The paired donor program at MSTH began in 2008 and has helped to pioneer the field of paired donation, successfully transplanting patients from across the U.S. and international pairs from Canada and Italy. The program’s success hinges on a team approach along with a world-class immunology laboratory. “Our group likes a challenge,” Bingaman said when talking about difficult-to-match patients who have travelled from near and far to receive exchange transplants in San Antonio. “We never get tired of giving folks their lives back, free from a dialysis machine.

"“A special emphasis is on blood type and antibody matching,” he continued. “We ensure each exchange recipient receives a kidney from a donor who is a complete or very close match, often making it unnecessary to utilize high-risk desensitization therapies to enable a transplant between incompatible pairs.”

Interview in Amsterdam on how to be a professor...video

I was recently in Amsterdam, where I was interviewed at the UvA's "Room for discussion." Essentially I was asked how to be a professor...the video is about an hour (and the annoying music at the beginning ends almost immediately:)

Here's another link, together with a story headlined "markets as essential as language"
http://www.foliaweb.nl/wetenschap/eredoctor-alvin-roth-markten-even-essentieel-als-taal/

Assisted suicide becoming less repugnant?

The NY Times has the story (and it involves a name change): ‘Aid in Dying’ Movement Takes Hold in Some States

"Helping the terminally ill end their lives, condemned for decades as immoral, is gaining traction. Banned everywhere but Oregon until 2008, it is now legal in five states. Its advocates, who have learned to shun the term “assisted suicide,” believe that as baby boomers watch frail parents suffer, support for what they call the “aid in dying” movement will grow further.

In January, a district court in New Mexico authorized doctors to provide lethal prescriptions and declared a constitutional right for “a competent, terminally ill patient to choose aid in dying.” Last May, the Vermont Legislature passed a law permitting it, joining Montana, Oregon and Washington. This spring, advocates are strongly promoting “death with dignity” bills in Connecticut and other states.

Public support for assisted dying has grown in the past half-century but depends in part on terminology. In a Gallup Poll conducted in May, for example, 70 percent of respondents agreed that when patients and their families wanted it, doctors should be allowed to “end the patient’s life by some painless means.” In 1948, that share was 37 percent, and it rose steadily for four decades but has remained roughly stable since the mid-1990s.

Yet in the same 2013 poll, only 51 percent supported allowing doctors to help a dying patient “commit suicide.”

About 3,000 patients a year, from every state, contact the advocacy groupCompassion & Choices for advice on legal ways to reduce end-of-life suffering and perhaps hasten their deaths.

Giving a fading patient the opportunity for a peaceful and dignified death is not suicide, the group says, which it defines as an act by people with severe depression or other mental problems."

Competition between colleges

Wei-Cheng Chen and Yi-Cheng Kao have a paper on college admissions that focuses on the practice of universities in a number of Asian countries of scheduling their admissions exams on the same day, so that students must choose which school to apply to among those whose exam is on the same day.

Simultaneous screening and college admissions, Economics Letters, Volume 122, Issue 2, February 2014, Pages 296–298

Abstract
We analyze a simultaneous screening problem in competition among top schools. The model predicts that when the second best school has similar prestige to the best one it could attract better students by choosing the same entrance examination date.

Same sex marriage comes to Scotland

The BBC  has the story: Scotland's same-sex marriage bill is passed

"MSPs voted by 105 to 18 in favour of the Marriage and Civil Partnership (Scotland) Bill.

The Scottish government said the move was the right thing to do but Scotland's two main churches were opposed to it."

HT: Peter Biro

WSJ: "I gave away a kidney, would you sell one?"

Dimitri Linde, a non-directed donor who started a kidney exchange chain writes in the WSJ yesterday:

I Gave Away a Kidney. Would You Sell One?

...
"To obviate the kidney shortage, we should heed the recommendation of Nobel Prize-winning economist Gary Becker and others by making it legal to compensate donors. Currently, the National Organ Transplant Act bans the "sale" of any human organs in the U.S. Those who oppose compensation object to its ramifications for donors and society. They argue that the poor will be exploited, and that people should give out of the goodness of their hearts.

But these lofty sentiments ignore the fact that 18 transplant candidates die each day. As the legal scholar Richard Epstein has put it: "Only a bioethicist could prefer a world in which we have 1,000 altruists per annum and over 6,500 excess deaths over one in which we have no altruists and no excess deaths."

Yet absent such policy changes, which have little traction in Washington, right now transplant chains are the best tool to facilitate donations. Chains begin with a would-be recipient identifying a donor—say, a man with polycystic kidney disease and his wife. In most cases, a potential donor doesn't have a compatible blood and tissue type with the intended recipient, so this spousal pair would likely be a poor match. (Incompatibility can marginalize the life span of the transplant, or preclude the body from accepting it at all.)

That's where organizations like the National Kidney Registry, a nonprofit computerized matching service, come in. The NKR and similar nonprofits work with hospitals across the U.S. to create large national exchanges, linking incompatible and poorly compatible pairs to highly compatible counterparts elsewhere. Additionally, by working with living donors, these matching services furnish kidneys that endure, on average, twice as long as equally compatible cadaver transplants.

Through groups like NKR, altruistic donors—people willing to donate to an anonymous person—initiate "donor chains," catalyzing multiple donations. Inspired by reading about a 60-person chain begun by such a donor, I entrusted the NKR to select my recipient. Their software churned up a highly compatible match for me more than a thousand miles away. Concurrent with receiving a kidney, my recipient's incompatible donor gave to a commensurately strong match. A courier delivered this donor's organ to a third hospital in yet another region of the country, completing the exchanges."

Perfect Strangers: kidney donation movie

I went to see Perfect Strangers last night at Stanford, by Stanford's documentary filmmaker Jan Krawitz.
It was followed by a panel discussion by Krawitz, Stanford philosopher Debra Satz, and two non-directed kidney donors, one of whom was the main character in the film. Both initiated non-directed donor chains.

The other donor was the subject of this 2011 blog post A kidney donor argues that selling kidneys should be legal.

Directed deceased organ donation

Here's a story from Modesto about a relatively rare directed donation of deceased donor organs: Dad selects recipients of Modesto woman’s kidneys after car crash

"The lives of two organ recipients and the father who lost a young daughter are linked by “directed donation,” in which a person chooses recipients for organ donations.

"Nearly 3,000 Californians received organ transplants from 1,279 donors who lost their lives in 2013. Families of about 190 of the donors had at least one specific person in mind to whom they wanted to give an organ. But after considering whether the recipient was on the donor list, was well enough to undergo surgery and was a biological match to the donor, only a quarter of the chosen recipients received the organs they needed.

"In the case of 27-year-old Modestan Stephanie Methvin, both recipients were able to accept a kidney, and both are also from Stanislaus County.

“It is really rare in this case that both folks were able to accept the kidneys,” said Tony Borders, spokesman for the California Transplant Donor Network." 

More on the market for kidneys in Iran

Here's an article on the market for kidneys in Iran that I missed when it came out, recently pointed out to me by Mohammad Akbarpour

Kidney International (2012) 82, 627–634; doi:10.1038/ki.2012.219; published online 6 June 2012

The Iranian model of living renal transplantation

Mitra Mahdavi-Mazdeh¹

¹Iranian Tissue Bank Research & Preparation Center, Tehran University of Medical Sciences, Tehran, Iran

Correspondence: Mitra Mahdavi-Mazdeh, Iranian Tissue Bank Research & Preparation Center, Tehran University of Medical Sciences, Tehran, Iran. E-mail: mmahdavi@sina.tums.ac.ir

Received 6 March 2012; Revised 28 March 2012; Accepted 5 April 2012
Advance online publication 6 June 2012

Topof page

Abstract

Organ shortage for transplantation remains a worldwide serious problem for kidney patients with end-stage renal failure, and several countries have tried different models to address this issue. Iran has 20 years of experience with one such model that involves the active role of the government and charity foundations. Patients with a desperate demand for a kidney have given rise to a black market of brokers and other forms of organ commercialism only accessible to those with sufficient financial resources. The current Iranian model has enabled most of the Iranian kidney transplant candidates, irrespective of socioeconomic class, to have access to kidney transplantation. The Iranian government has committed a large budget through funding hospital and staff at the Ministry of Health and Medical Education by supporting the brain death donation (BDD) program or redirecting part of the budget of living unrelated renal donation (LURD) to the BDD program. It has been shown that it did not prevent the development and progression of a BDD program. However, the LURD program is characterized by several controversial procedures (e.g., confrontation of donor and recipient at the end of the evaluation procedure along with some financial interactions) that should be ethically reviewed. Operational weaknesses such as the lack of a registration system and long-term follow-up of the donors are identified as the ‘Achilles heel of the model’.

Markets and microbes

Economists are sometimes accused of scientific imperialism, but what is it when biologists find market models useful, as in this paper from PNAS?

Evolution of microbial markets

Abstract: Biological market theory has been used successfully to explain cooperative behavior in many animal species. Microbes also engage in cooperative behaviors, both with hosts and other microbes, that can be described in economic terms. However, a market approach is not traditionally used to analyze these interactions. Here, we extend the biological market framework to ask whether this theory is of use to evolutionary biologists studying microbes. We consider six economic strategies used by microbes to optimize their success in markets. We argue that an economic market framework is a useful tool to generate specific and interesting predictions about microbial interactions, including the evolution of partner discrimination, hoarding strategies, specialized versus diversified mutualistic services, and the role of spatial structures, such as flocks and consortia. There is untapped potential for studying the evolutionary dynamics of microbial systems. Market
theory can help structure this potential by characterizing strategic investment of microbes across a diversity of conditions.

************
Update: my joke about imperialism was a bit opaque it turns out. To be clear, I'm a big admirer of cross fertilization between fields. Here's an earlier post about Noe's work...

Tuesday, April 13, 2010

Biological markets: exchange of goods and services among non-human species

From the web pages of the French scientist Ronald Noe:

Data for job matching might come from new sources--even video games

Catherine Rampell at the NY Times has the story, focusing on the startup Knack: Your Next Job Application Could Involve a Video Game

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.”