Two bills aimed at increasing the number of transplants

The Niskanen Center has a post on two proposed pieces of legislation (together with some thoughts on why incremental policy oriented work is important):

TWO NEW BILLS WILL HELP WITH THE KIDNEY SHORTAGE. BUT PAYING DONORS COULD HELP EVEN MORE.
BY SAMUEL HAMMOND

Here's the  first paragraph of their article, and the  last.


"Last week, the Organ Donation Clarification Act was released by Rep. Matt Cartwright (D-PA) with 14 cosponsors. The bill would clarify the National Organ Transplant Act’s (NOTA) definition of “valuable consideration,” making it clear that donors can be compensated for medical expenses and lost wages. It would also permit the U.S. government to run pilot programs to test the viability of noncash rewards to incentivize donors. And now this week, Rep. Tom Rice (R-SC) has announced a set of amendments to NOTA that seek to orient the Health Resources and Services Administration toward increasing organ procurement, rather than simply distributing an inadequate supply."

...
"At the same time, the Niskanen Center’s overall mission eschews ideal theories in favor of pragmatic policy change. Thus, as much as I’d love to see someone like Al Roth appointed as the organ transplant czar, with a mandate to design an optimal market in organs, politics is a long game of persuasion and compromise. That’s why the two new bills from Reps. Cartwright and Rice remain immensely important, even if they don’t nearly go far enough."

Interview on market design and repugnance with Yale sophomore Eric Wallach

Here's the transcript of a recent telephone interview I did with ERIC WALLACH, a sophomore at Yale, for The Politic, Yale’s undergraduate journal of politics and culture.

 An Interview with Alvin Roth

Here's the one Q&A he chose as a highlight, at the top of the page:

"How do you approach issues that may be ethically constrained? Do you think there’s a way to minimize the value judgements you make as an economist?

It’s interesting you ask the question that way. For a long time, economists seemed to agree with the implicit assumption of your question that we should minimize the ethical judgements we make. I’m not sure that’s a universal position anymore. Among economists, there’s some discussion that maybe we should be taking ethical positions about some of the markets we see, and especially with repugnant markets."

Transcripts of conversations are a bit disorganized, but this interview covered some issues  different from the ones I normally get asked about (and it's short).

**********

Update: and here's Mr. Wallach's interview with Avinash Dixit:

An Interview with Avinash Dixit, Professor of Economics Emeritus at Princeton University

Nevanlinna Prize winner Constantinos Daskalakis, and the Fields medalists (and one of the Fields medals)

Here's a video that touches on his work on computational complexity of Nash equilibria, and auctioning multiple items.



Here's some more on that from AFT, focusing as well on the Fields medalist Alessio Figalli

THE 2018 FIELDS MEDAL AND ITS SURPRISING CONNECTION TO ECONOMICS!



And here's more still, from Quanta:

2018 Fields Medal And Nevanlinna Prize Winners


And in case less is more, here's a short announcement from Science:
Five superstars win ‘math’s Nobel Prize’

And then there's this, from the prize ceremony in Rio...
Winner of top mathematics prize has medal stolen from him minutes later

Politico summarizes the Backpage story

Here's an article for those who haven't been following this first amendment/prostitution/human trafficking story...

The Sex-Trafficking Case Testing the Limits of the First Amendment
How a couple of crusading journalists made a fortune selling adult escort ads and in the process became unlikely and widely reviled First Amendment advocates.
By PAUL DEMKO July 29, 2018

Many of the people quoted focus on the motivations of the protagonists (get rich, versus defend the First Amendment press freedoms...). I wonder what role if any those questions will play in the legal proceedings.


Here are my other posts about  Backpage and related matters.

How to split the check using social skills or mechanism design

The Washington Post ran a column yesterday that offers advice on
How to split the check without the accusations and awkwardness.

The article points out that restaurants' point of sale software can help if you alert the waiter before you order.

For other fair-division problems, here's a website, Spliddit , that offers tools (and the underlying references to the literature) to help:

• SHARE RENT 
• SPLIT FARE
• ASSIGN CREDIT
• DIVIDE GOODS
• DISTRIBUTE TASKS

If your problem meets the assumptions of the underlying model, you can take it from there.

This seems to be a project of Ariel Procaccia and various colleagues, with Hervé Moulin   as an advisor.

He has another site, RoboVote, which seems more like a general social choice tool for aggregating information or preferences.

A look inside Harvard's admissions process

College admissions is a matching process--you can't just study at an elite university, even if you can afford the tuition--you first have to be admitted.

Harvard's admissions process is the subject of a lawsuit, and the discovery process is shedding some light on the deliberations that go on behind the closed doors of the admissions committee.  Here's an account from the NY Times:

‘Lopping,’ ‘Tips’ and the ‘Z-List’: Bias Lawsuit Explores Harvard’s Admissions Secrets

Now you know some Harvard admissions jargon: "tips" are aspects of a candidates case that might tip him or her over the bar to admission. "Lops" are people tentatively admitted who get lopped off the admit list as it is trimmed to create a class that is balanced the way the admissions office wants.  And the "Z-List" consist of people admitted at the last minute, and required to defer admission for a year, who often have family connections to Harvard.

Ant financial

When I visited Hangzhou recently I learned a bit about Ant Financial, the offspring of Alibaba and the proprieter of AliPay.  Here's a story from the WSJ about how big they've grown, and the attention it is starting to bring them from Chinese regulators:

Jack Ma’s Giant Financial Startup Is Shaking the Chinese Banking System
Ant Financial is transforming how Chinese run their daily finances, drawing flak from big banks and warning shots from the government

"It handled more payments last year than Mastercard , controls the world’s largest money-market fund and has made loans to tens of millions of people. Its online payments platform completed more than $8 trillion of transactions last year—the equivalent of more than twice Germany’s gross domestic product.

"Ant Financial Services Group, founded by Chinese billionaire Jack Ma, has become the world’s biggest financial-technology firm, driving innovations that let people use their phones for buying insurance as easily as groceries, enabling millions to go weeks at a time without using physical cash.

"That success is also putting a target on the company’s back. China, even more than the U.S., is now under pressure to reckon with the disruptive power of a financial-technology giant."

Compensation for bone marrow/blood stem cells: where are we now?

Here's a paper in the Johns Hopkins series of mostly student papers, Studies in Applied Economics, that brings us up to date on the state of bone marrow compensation in the U.S.

An Examination of the Issue of Bone Marrow Compensation
By Valerie Vilariño

"Although  compensation  for  bone  marrow  is  no  longer  regulated  by  the federal  government, there are many obstacles it must overcome before it becomes commonplace. Citizens who live in states that ban it may not be able to participate in either end of compensation. This is due to grey areas between the laws of the state governments and the Commerce Clause of the U.S. Constitution. For example, a patient living in a state that bans compensation may not be able to receive bone marrow from a donor who was compensated, even if the donor lives in a state where compensation is allowed, because it breaches the law of the state in which the patient lives. However, this exchange constitutes interstate commerce since the donor and the patient are not in the same state. These types of legal uncertainties often result in cases being heard before the Supreme Court to determine precedents for similar scenarios in the future.36

"Then  there  are  the  practical  difficulties.  At  the  moment,  no  compensatory  bone  marrow registries exist. According to Doug Grant of Hemeos, the main reason for that is that the NMDP opposes  the  compensation  of  bone  marrow.  Both  MoreMarrowDonors.Org  and  Hemeos, despite  having  had  different  business  plans  in  the  way  they  were  planning  on  going  about compensating donors, were forced to close because of procedures indirectly imposed on them by  Be  the  Match.  Grant  told  me  in  an  interview  that  he  closed  Hemeos  in February  2017 because as a startup, the fight against regulation was too much for Hemeos to overcome. By the time that compensation became unquestionably legal, the startup had run out of capital. For compensation to become a reality, there must be registries that are willing to compensate. Because the NMDP so strongly opposes compensation, the experts I talked to agreed that the only option for a compensatory bone marrow registry to exist is for it to be a competitive, parallel registry to that of BE the Match.

"This  presents  other  logistical  difficulties  because  currently  Be  the  Match  is  the  registry  that most,if not all,physicians use when looking for a match for their patient. For a new registry to compete with Be the Match, not only would it, like Hemeos, have to develop its own software to provide transplant centers with, but it would also need to make connections with individual hospitals so that they begin to search the registry. Growing a registry to fully compete with Be the Match’s could take years  given  that  there  is nocentralized  process  by  which  hospitals partner  with  bone  marrow  registries.  Each  hospital  would  have  to  make  an  individual partnership with the compensatory registry. Furthermore, there is currently little incentive for entrepreneurs  to  tackle  this  seemingly  daunting  startup  possibility  since  the  entire  bone marrow market accounts for only $3 million to $4 million a year.
...
"Lastly,  as  previously  mentioned,  47  percent  of  the  matches  made  by  Be  the  Match include either  a  foreign  donor  or  recipient.  Compensation  poses  a  problem  in  those  cases  because many  of  the  cooperative  registries  that  partner  with  Be  the  Match  are  national  registries  of countries where compensation is not legal. By making compensation legal in the United States, some  of  these  partnerships  could  be  strained, potentially leading  to  a  significant  loss  of international matches. All of these are barriers that would need to be somehow overcome in order for compensation not only to be realistic but also for it to accomplish its goal of helping to relieve the scarcity of bone marrow matches."
********

HT: Frank McCormick

PBS asks: should the U.S. follow Iran in allowing a market for kidneys for transplant?

PBS asks the question
Iran pays kidney donors. Should the U.S. follow?

You can read the transcript or watch the video at the link.

HT: Mohammad Akbarpour

Surrogacy law in Israel

Haaretz has the story of the recent expansion of access to surrogacy in Israel, which however excludes same sex couples.

Why the Battle for Gay Rights in Israel Passes Through Parenthood, Not Marriage

"Thousands of Israelis walked out of their workplaces and took to the streets Sunday, to protest the government’s denial of gay men’s rights to have children through surrogacy.

"The protest over the legislation highlights how in a country where marriage is governed by religious authorities, parenthood is seen as the key to equality.

"The new legislation loosened surrogacy regulations in Israel, giving single women and women unable to become pregnant for medical reasons the right to apply for state support for surrogacy. However, an additional clause that would have granted the same rights to single fathers – and, by extension, gay couples – was nixed."

Modern slavery, in supply chains and around the world

The Global Slavery Index recently issued its report for 2018.
They say: "In the context of this report, modern slavery covers a set of specific legal concepts including forced labour, debt bondage, forced marriage, slavery and slavery-like practices, and human trafficking."

While we're apparently all lucky not to live in N. Korea, the report doesn't stop there. For one thing, it suggests that a lot of supply chains may involve involuntary labor of various sorts.  The NY Times headline summarizes the aspects of the report that might be of most concern to readers of this blog:

Report Finds Surprisingly High Rate of Slavery in Developed Countries

"The 2018 edition of the index estimates that more than 40 million people around the world are trapped in modern slavery — including what Walk Free called a surprisingly high number in developed nations like the United States, France, Germany and others.

“Given these are also the countries taking the most action to respond to modern slavery, this does not mean these initiatives are in vain,” the survey said. “It does, however, underscore that even in countries with seemingly strong laws and systems, there are critical gaps in protections for groups such as irregular migrants, the homeless, workers in the shadow or gig economy, and certain minorities.”

"In the United States, more than 400,000 people, or one in 800, are living in modern slavery, the report said. The United States is also the largest importer of what the report called “at-risk” products, or those at least partly manufactured by workers engaged in forced labor.

"These products, estimated to be worth at least $354 billion, include mobile phones, computers, clothing and food like fish and cocoa, the report said. The United States imports more than 40 percent of the total."

Kidney Exchange at Methodist of San Antonio

Good matching algorithms and software, innovative histocompatibility tests, recruiting lots of compatible pairs and good surgery and administration combine to make an exemplary single center kidney exchange program:

400 Kidney Paired Donor Transplants at a Single Center; The Methodist San Antonio Experience
A. Bingaman, M. Kapturczak, I. Ashlagi, C. Murphey.

Background: Kidney paired donation (KPD) has become the standard of care for incompatible living donor pairs. Several mature national KPD programs exist yet KPD transplants only represent about 11% of total live donor transplants in the U.S., less than predicted by computer modeling. Methods: We initiated a single center KPD program in 2008. Consenting pairs were entered into our KPD database with blood types, HLA types and unacceptable antigens individually assigned based upon single antigen bead analysis. Results: Between March 2008 and October 2017 our single center KPD program has done 400 KPD transplants, representing 26% of total living donor transplants at our center. These transplants include 57 2-way exchanges, 36 3-way exchanges, 9 4-way exchanges, 6 5-way exchanges, 2 6-way exchanges and 13 non-directed donor (NDD) initiated chains ranging in length from 3-23 recipients. 218 patients were sensitized HLA incompatible with their original donors including 111 (51%) with cPRA >80% and 53 (24%) with cPRA >99%. 62 recipients (15.5%) were re-transplant patients. A total of 43 patients underwent desensitization for positive flow crossmatch or ABO incompatibility. A total of 222 (55%) blood type O donors were utilized of which 212 (95.5%) were transplanted into blood type O recipients or non-O recipients with cPRA >80%. 22 blood type A2 donors were utilized, of which 15 (68%) were transplanted into non-A recipients. 51 compatible pair donors were utilized of which 48 donors (94%) were blood type O or A2, and 3 donors (6%) were blood type A1. Compatible pairs participated in a total of 155 KPD transplants. All compatible pair recipients received kidneys from younger donors. Overall one year graft survival is 98.7%. Conclusions: We report the largest single center KPD program in the world. With limited NDDs, KPD programs must utilize blood type A2 donors and compatible pairs in order to transplant blood type O recipients effectively. To transplant the most highly sensitized patients, combination of KPD and desensitization is very effective with excellent outcomes.

CITATION INFORMATION: Bingaman A., Kapturczak M., Ashlagi I., Murphey C. 400 Kidney Paired Donor Transplants at a Single Center; The Methodist San Antonio Experience Am J Transplant. 2017;17 (suppl 3).

**************

Earlier:

Utilization of Compatible Pairs in a Large Kidney Paired Donation Program

A. Bingaman, F. Wright, M. Kapturczak, L. Shen, C. Murphey

Methodist Specialty and Transplant Hospital, San Antonio, TX
Southwest Immunodiagnostics, San Antonio, TX

Meeting: 2013 American Transplant Congress

Background: Our center has established a very large single center kidney paired donation (KPD) program. A significant barrier to KPD transplant has been the unbalanced blood types in the KPD pool which develops over time, including many blood type O recipient candidates and many non-O donor candidates. Additionally, highly sensitized recipient candidates are in competition for rare donor HLA types. Computer modeling has shown that KPD can be significantly expanded by participation of compatible pairs, particularly to enrich the pool of O donors and utilize donors with rare HLA types. Here we report our experience utilizing compatible pairs as a part of our KPD program. Methods: All recipients with consented incompatible donors were entered into our KPD database. In addition, compatible pairs with older donors that were not HLA identical were approached for consent into the database. Compatible recipients were only offered a kidney from a younger exchange donor. Results: Since February 2009, 23 compatible pairs have been utilized in KPD transplants at our single center, including 14 2-way exchanges, 5 3-way exchanges and 4 chain exchanges (chain lengths 10-23 recipients.) Of the compatible pairs, 8 recipients were blood type O and 15 were non-O; 21 donors were blood type O, 1 was type A2 and 1 blood type A1. In marked contrast, of the incompatible pairs which benefited, 20 recipients were blood type O and 3 were non-O; 10 donors were blood type O, 11 were blood type A1 and 2 blood type B. Of the compatible KPD recipients, none were sensitized, whereas of the incompatible recipients 15 were sensitized, 9 with cPRA >80%. All compatible KPD recipients were transplanted with younger kidney donors. The median age of compatible donors was 57 years whereas the median age of incompatible donors was 29 years. Patient and allograft survival are 100% for both compatible and incompatible groups, median follow up 28 months. The compatible KPD option was viewed as favorable by the majority of pairs approached for consent. Conclusions: This is the largest reported experience of compatible pairs utilized in KPD. When employed in a large KPD program, compatible pairs with O donors significantly expand KPD options for both blood type incompatible pairs and highly sensitized recipients. Utilization of compatible pairs should be expanded nationally to increase the opportunity for incompatible pairs to be transplanted through KPD.

Design of fisheries--EURO Excellence in Practice Award to Bichler, Ferrell, Fux, and Goeree

Congratulations to the winners, and to the fishermen and the fish for this recent award for market design.

EURO Excellence in Practice Award 2018

The winners of the 2018 EURO Excellence in Practice Award are:

Martin Bichler, Technical University of Munich

Douglas Ferrell, Department of Primary Industries, Fisheries Analysis

Vladimir Fux, TUM

Jacob Goeree, Business School, University of New South Wales

A combinatorial exchange for fishery access rights

We present the design and implementation of a combinatorial exchange for trading catch shares in New South Wales (NSW). The market provided a market-based response to a substantial policy problem in fisheries worldwide: the reallocation of catch shares among fishers in a cap-and-trade system designed to prevent overfishing.
The design needed to address several key challenges to overcome a long struggle about the right way to reallocate shares.
Participants wanted to be able to submit all-or-nothing package bids. Also, prices were required to be anonymous and linear such that sellers of two identical packages would get the same payment. These features were crucial for the adoption of the market design but difficult to accommodate in a market design. The requirements led to a computationally challenging allocation and pricing problem that addressed the key concerns of the stakeholders.
The market was organized in summer 2017 by the government and successfully put the shares into the hands of those who needed them most. The design nicely illustrates how computational optimization can provide new policy tools, able to solve complex policy problems that were considered intractable only a few years ago.

The EEPA 2018 jury consisted of Ulrich Dorndorf (chair), Erik Demeulemeester, John Poppelaars, Adam Ouorou, and Karl Dörner.

The award was presented at the closing session of the EURO 2018 Conference in Valencia (Spain).

*********

Here's an earlier post on fisheries:

Monday, February 16, 2009

Sustainable fisheries

A cri de cœur against assortative matching for French college admissions

A French op-ed discusses the new college admissions system, 'Parcoursup':

Derrière l’algorithme de Parcoursup, un choix idéologique.  Par Hugues Bersini.
Gtranslate: Behind Parcoursup's algorithm, an ideological choice

The objection seems to be to assortative matching, which results when students largely agree on the desirability of universities, and universities largely agree on the desirability of students.  As a result, few students from poor neighborhoods are matched to top college programs.

Two recent trips to China, in pictures

From Hangzhou, with Alibaba's Jack Ma, and overlooking West Lake, with the pagoda from the story of White Snake barely visible in the distance (but see Beijing Opera, below):

From Qingdao (where the beer comes from both Factory 1 and Factory 2),  at Lao Shan, and from the HiSense building:

In Beijing: Tsinghua conference (with Ed Hopkins, Jacob Goeree and Ben Roth), Beijing Opera (Madam White Snake), Temple of Heaven, and at DiDi with Will Cheng:

Effects of removing some financial dis-incentives to kidney donation through the National Living Donor Assistance Center (NLDAC)

Here's a recent paper looking at NLDAC. (I'm on their advisory board.)
It might help make the case for yesterday's proposed legislation...

Clinical Transplantation

 Volume 32, Issue 7

ORIGINAL ARTICLE

Full Access

Return on investment for financial assistance for living kidney donors in the United States

Amit K. Mathur 

Jiawei Xing 

David M. Dickinson 

Patricia H. Warren 

Kimberly A. Gifford 

Barry A. Hong 

Akinlolu Ojo 

Robert M. Merion

First published: 08 May 2018

https://doi.org/10.1111/ctr.13277

Abstract

Background

The National Living Donor Assistance Center (NLDAC) enables living donor kidney transplants through financial assistance of living donors, but its return on investment (ROI) through savings on dialysis costs remains unknown.

Methods

We retrospectively reviewed 2012‐2015 data from NLDAC, the United States Renal Data System, and the Scientific Registry of Transplant Recipients to construct 1‐, 3‐, and 5‐year ROI models based on NLDAC applications and national dialysis and transplant cost data. ROI was defined as state‐specific federal dialysis cost minus (NLDAC program costs plus state‐specific transplant cost), adjusted for median waiting time (WT).

Results

A total of 2425 NLDAC applications were approved, and NLDAC costs were USD $6.76 million. Median donor age was 41 years, 66.1% were female, and median income was $33 759; 43.6% were evaluated at centers with WT >72 months. Median dialysis cost/patient‐year was $81 485 (IQR $74 489‐$89 802). Median kidney transplant cost/patient‐year was $30 101 (IQR $26 832‐$33 916). Overall, ROI varied from 5.1‐fold (1‐year) to 28.2‐fold (5‐year), resulting in $256 million in savings. Higher ROI was significantly associated with high WT, larger dialysis and transplant costs differences, and more NLDAC applicants completing the donation process.

Conclusions

Financial support for donor out‐of‐pocket expenses produces dramatic federal savings through incremental living donor kidney transplants.

Proposed new legislation: Organ Donor Clarification Act

Here's an Act that would encourage evidence-based policy towards reducing the dis-incentives to donate a kidney or part of a liver for transplantation.  (Evidence is not so popular these days, and compensation for donors is a red flag, so I expect it may yet meet with opposition, as did a differently composed previous attempt in 2016 .  So far I can't find the current version online--it looks like it will eventually be here-- but the offline version I've seen looks like something I will support:)

CARTWRIGHT ANNOUNCES LEGISLATION TO INCREASE ORGAN DONATION

Jul 19, 2018 

Press Release

Effort Comes Amidst Shortage, Resulting in Thousands of Preventable Deaths Every Year

Washington, DC – Addressing our nation’s dire organ transplant shortage U.S. Representative Matt Cartwright (D-PA) introduced the Organ Donor Clarification Act on July 19th.There are 115,000 people on the organ transplant waiting list and 20 people die every day as they wait for an organ. This bipartisan legislation will remove existing hurdles for donation and test out new ways to increase donations.

“This is life and death; 20 people die every day because they could not survive the wait for a viable organ,” Rep. Cartwright said.  “Kidney waiting lists in major cities can last from five to ten years, which is often longer than a patient can survive on dialysis.”

The number of people in the United States with kidney failure has increased by nearly 20% since 2000 and there are currently over 95,000 Americans on the national waitlist for a kidney. Each year 17,000 patients receive a kidney transplant, while about 35,000 new patients are added to the kidney waiting list. As many as 80,000 additional patients may be good candidates for kidney transplant, but have never even been listed. 

This legislation removes existing barriers that donors face under current law and allows for a pilot program to test the effectiveness of non-cash incentives to increase the supply of organs for transplantation.

Currently, organ transplantation is governed by the National Organ Transplant Act (NOTA) of 1984.  This law prohibits buying or selling organs for “valuable consideration.” 

“Confusion about what constitutes valuable consideration hampers donation by scaring people away from reimbursing organ donors for things like medical expenses and lost wages,” said Rep. Cartwright.  “Reimbursements are legal under NOTA, but the law’s lack of clarity and criminal penalties have created uncertainty that has prevented or delayed reimbursements in many cases. Additionally, this bill will allow experts and scientists to run pilot programs – subject to ethical review and government oversight – to test the effect of non-cash incentives in reducing the organ transplant waiting list.”

The expanding kidney wait list has also become a burden on our nation’s finances, as costs for dialysis and other intermediary treatments become more expensive each year. The taxpayer ends up footing the bill through Medicare and other social service programs. Experts project that eliminating the waiting list would save taxpayers well in excess of $5.5 billion per year in medical costs and billions of dollars more in savings to other social programs.

The Organ Donor Clarification Act would:

• Clarify that certain types of payments are not valuable consideration but are reimbursements for expenses a donor incurs.
• Allow government-run pilot programs to test the effectiveness of providing non-cash incentives to promote organ donation.  These pilot programs would have to pass ethical board scrutiny, be approved by HHS, distribute organs through the current merit based system, and last no longer than five years.

The Organ Donor Clarification Act has been endorsed by the following organizations:

• American Medical Association
• American Liver Foundation
• Americans for Tax Reform
• American Foundation for Donation and Transplantation
• American Transplant Foundation
• Chris Klug Foundation
• Donor to Donor
• Flood Sisters Kidney Foundation
• Foundation for Kidney Transplant Research
• Transplant First Academy
• WaitList Zero

The Bill is cosponsored by the following bipartisan members of the House of Representatives:

Rep. Jason Lewis (R-MN), Rep. Sanford Bishop (D-GA), Rep. André Carson (D-IN), Rep. Steve Cohen (D-TN), Rep. Brian Fitzpatrick (R-PA), Rep. Raul Grijalva (D-AZ),  Rep. Lynn Jenkins (R-KS), Rep. E.B. Johnson (D-TX), Rep. Mike Kelly (R-PA), Rep. Ro Khanna (D-CA), Rep. Tom Marino (R-PA), Rep. Jim McGovern (D-MA), Rep. Jared Polis (D-CO), Rep. Bill Posey (R-FL), Rep. Don Young (R-AK)

Manipulation by doctors of the Organ Allocation System Waitlist Priority

You will be shocked to learn that doctors and transplant centers respond to incentives in their effort to get scarce organ transplants for their own patients...

Here's a recent OPTN/UNOS white paper on the subject, concerning the waitlist for organs (such as hearts) for which physician decisions can influence patients' position on the waitlist.

Manipulation of the Organ Allocation System Waitlist Priority through the Escalation of Medical Therapies

"This white paper provides an ethical analysis of physicians’ practices of escalating care to waitlisted transplant candidates in order to increase their priority in the allocation system. Many in the transplant community perceive, as expressed explicitly in the medical literature23, that this practice of unnecessary escalation of care is widespread, and recognize that physicians may feel compelled to similarly manipulate the waitlist priority system so that their candidates are not disadvantaged as a result of the practices of others.

"For example, in heart transplantation, priority status can be influenced by the degree of therapeutic intervention applied to the transplant candidate, based on the assumption that therapeutic measures are a reliable indicator of disease severity.4 An unintended consequence of this approach is that a physician can raise the priority status of a patient by instituting more advanced therapeutic measures even in the absence of true medical necessity, a tactic some informally refer to as “gaming.”

"Due to the organ shortage, the transplant waitlist “is functionally a zero-sum rationing process.”5 Shortening wait times for some directly increases wait times for others. Thus, the practice of instituting more advanced therapies to shorten an individual’s wait time has no beneficial effect on wait times for the patient population in the aggregate. However, manipulating care to achieve a higher candidate priority can generate complications in candidates receiving such care while also jeopardizing public trust in the organ allocation system, which in turn, could reduce organ donation rates.

"OPTN/UNOS leadership requested an ethical analysis regarding the manipulation of the organ allocation system, particularly as it pertains to medically unnecessary escalation of interventions that are instituted for the sole purpose of increasing a candidate’s waitlist priority. The OPTNhas not previously commented on this issue."
...

"During the mid-late 1990s, three transplant hospitals in Chicago, IL were alleged by federal and state authorities to have falsely reported patients as critically ill in order to house them in the intensive care unit for the purpose of moving them to the top of the liver transplant waitlist.20 The hospitals denied any wrongdoing, but did receive financial penalties. These incidents generated questions about the integrity and fairness of the liver allocation system based on the alleged events.21,22

"In the last five years, prominent editorials described the widespread use of medical interventions that are not thought to be medically indicated in routine practice, but allow for patients to receive higher waitlist priority.23,24 This includes increased utilization of pulmonary artery (PA) catheters with continuous inotropes for the purpose of increasing the priority status on the waitlist of a patient with heart failure.25 While there are situations in which PA catheter use is appropriate, this intervention is associated with excessive adverse complications, which typically prohibits its routine use. When use of PA catheters was aligned with allocation priority, increasing use of PA catheters quickly followed.26 Further, vascular complications that preclude further catheterization have evolved to become a major justification for Status 1A exceptions, which are presumed to be related to overuse of PA catheters.27,28

"Increasingly, heart transplant candidates are being listed as Status 1A (the highest priority), which is largely based on the intensity and risk of the intervention used to treat the patient. This category was originally intended for potential transplant candidates expected to survive less than one week. Now, it’s not uncommon for Status 1A patients to have longer waitlist survival, and they may wait 6-12 months ."
...
"Multiple stakeholders stand to gain from manipulating the allocation system, including the candidate and the transplant hospital."

Matching endorsements to endorsers

The NY Times reports on speed dating of Youtube influencers and brands (and on newly relevant "moral turpitude" clauses concerning both parties):

Inside the Mating Rituals of Brands and Online Stars
By Daisuke Wakabayashi

"Recently at the Anaheim Convention Center, about 50 people entered a room decorated as a stylish lounge for a speed dating event. They moved from table to table every 20 minutes, exchanging small talk and getting to know each other.
But the participants were not looking for love. They were YouTube stars and marketing executives from companies like Uber and Amazon seeking an advertising union.

"Deals between big brands and viral online video performers, once an informal alternative to traditional celebrity sponsorships, are quickly maturing into a business estimated to reach $10 billion in 2020.
...
"As the attention and money paid to stars on sites like YouTube and Instagram balloon, the stakes for both them and the brands to find the right match are rising. The speed dating event, held during VidCon, the online video industry’s annual convention, was one way the two sides are testing each other out.
...
"Most advertising deals with YouTube or Instagram stars now include a “morality clause.” One such agreement, shown to The New York Times, stated that a creator would agree to take down any content within 12 hours if the brand determined that the talent had promoted a competing product, posted “racy content” on social media or performed “an act of moral turpitude.”
...
Increasingly, [an agent] wants the same right for his clients because they have just as much to lose if a company becomes embroiled in scandal, such as the right to take down a video sponsored by a company if that brand’s executives are caught sexually harassing staff."
**********

Update: and here's a recent paper on the subject:

The Market for Influence

39 Pages Posted:  

Itay P Fainmesser

Johns Hopkins University - Carey Business School

Andrea Galeotti

University of Essex

Date Written: July 3, 2018

Abstract

Influencer marketing is the fast growing practice in which marketers purchase product endorsements from influencers, who are individuals with many followers and strong reputations in niche markets. This paper develops a model of the market interactions between influencers, followers and marketers. Influencers trade-off the increased revenue they obtain by posting more paid endorsements, with the negative impact that this has on their followers’ engagement, which in turn affects the price marketers are willing to pay for their endorsement. Our analysis provides testable predictions on how the price that influencers receive depends on the size of their audience, and how an improvement in the online search technology affects influencers’ competition for followers and marketers. We show that, in equilibrium, over- and under-provision of paid endorsements coexist. We evaluate the strategic effects of recent, trans- parency motivated, policy interventions implemented by competition authorities in the US and Europe, requiring influencers to clearly mark the content that is sponsored by marketers.

Compensation for plasma donors--calls for a ban in Canada

At the same time as there are calls for decriminalizing drug use in Canada (see yesterday's post), there are calls for bans on compensating plasma donors. (Repugnance is a big topic..)

This post collects some thoughts on compensation for plasma donors, following my participation in the recent Plasma Protein Forum.

Much discussed there is the rash of recent legislation and proposed legislation in Canada to ban compensation for donors (a sort of repugnance event...).

E.g.
B.C. joins 3 other provinces in banning payment for blood and plasma
Alberta, Ontario and Quebec already have laws prohibiting profit from blood donations

Senator introducing bill to ban payments for blood donation
"“The point of this bill is better safe than sorry,” Wallin said.

“Canadian blood donors are not meant to be a revenue stream.”

Time to end for-profit plasma donations

Canada must never allow another tainted blood crisis and must put an end to cash-for-blood clinics. by (Senator) PAMELA WALLIN

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One perplexing feature of this debate is that Canada already buys lots of plasma from the U.S., where it is supplied by paid donors. No one seems to be suggesting that should be changed.

(Here are my posts to date on plasma in Canada.)

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In related notes, China seems to be ramping up it's "source" plasma collection (obtained at the source via plasmapheresis, as distinct from "recovered" plasma obtained from whole blood donations), with collection of about 7 million liters in 2017.  My understanding is that Chinese law forbids the importation of blood products except for albumin.

See this Lancet editorial from 2017:

The big business of blood plasma

"China,  a  country  that  holds  the  questionable  honour  of  being a world leader in liver disease, is now also the highest consumer  of  serum  albumin,  using  300  tonnes  annually,  roughly  half  of  the  worldwide  total  use,  according  to  an  article  in  the  Financial  Times. 

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In Brazil, compensation of plasma donors is forbidden (along with compensation of organ donors) in the Constitution, article 199

"(4) The law establishes the conditions and requirements to allow the removal of human organs, tissues, and substances intended for transplantation, research, and treatment, as well as the collection, processing, and transfusion of blood and its by products, all kinds of sale being forbidden."