It's time to explore compensation for kidney donors: Dr. Arthur Matas in JAMA Surgery

 Dr Arthur Matas, the distinguished surgeon who directs the renal transplant program at the University of Minnesota, is tired of seeing his patients die for lack of an organ transplant.  Here's his latest plea to the profession.

A Regulated System of Incentives for Kidney Donation—Time for a Trial!, by Arthur J. Matas, MD, JAMA Surg. Published online June 2, 2021. doi:10.1001/jamasurg.2021.1435

"In the past 2 decades, numerous attempts have been made to increase the number of both living donors (eg, nondirected donors, paired exchange) and deceased donors (eg, donation after circulatory death), yet there has been little change in the number of donated kidneys. With increasing need but limited supply, the waiting list for a transplant has grown and waiting times have increased, with substantial negative consequences for patients in the US. In the last 20 years, more than 89 000 candidates in the US died while waiting for a kidney. An additional 54 838 were removed from the waiting list because of becoming too sick to undergo a transplant.1

"A regulated system of incentives for donation could provide a sizable increase in the number of kidneys available for transplant. Yet incentives for kidney donation are illegal in the US. Proposals for a regulated system have existed since the 1980s. But, in addition to other objections to changing the law (discussed later in this article), the constant refrain has been “let’s see if this next innovation works first.” Although the previously described innovations have been important advances, none have significantly reduced the waiting list. Given the ongoing failure to provide the best treatment option for a large segment of the patient population, it is time to move forward with trials of incentives.

...

"Trials of incentives for kidney donation may not be successful. Yet while trials have been prohibited, donation rates have been stagnant and wait-listed patients are dying or becoming too sick to undergo a transplant. The American Society of Transplantation and the American Society of Transplant Surgeons have endorsed moving toward pilot projects of incentives.3 The US government, recognizing the benefits of transplant, recently initiated incentivization of providers for directing kidney failure patients to transplantation9 and provided lifetime coverage for immunosuppressive drugs.10

"It is time to move past the feelings that incentives are wrong to the reality that as a result of a potentially preventable shortage of organs, patients on the waiting list are dying or becoming too sick to transplant. We need to act to determine if we can improve outcomes for these patients while providing benefit to, and not harming, incentivized donors. It is time for professional societies and patient groups to advocate for changing the law to allow trials of incentives for donation."

Governments should buy kidneys, in Journal of Applied Philosophy

 Philosophers argue differently than economists do, but can sometimes reach similar conclusions.  And (like economists) philosophers can sometimes reach very different conclusions from one another. Here's a philosopher who comes out in favor of allowing governments to pay for kidneys, to be allocated to transplant recipients without requiring any payment from them. Among the philosophical counterarguments to a market that must be dealt with along the way are those such as "it is unjust to be paid to do one's duty" (i.e. since the healthy may be argued to have a duty to the ill, we shouldn't try to reduce the shortage of organs by compensating donors because they have a duty to be altruistic...).  I don't think this is a line of argument that an economist would feel compelled to respond to.

 Why States Should Buy Kidneys, by Aksel Braanen Sterri, Journal of Applied Philosophy, First published: 02 June 2021 https://doi.org/10.1111/japp.12523

ABSTRACT: In this article, I argue we have collective duties to people who suffer from kidney failure and these duties are best fulfilled through a government-monopsony market in kidneys. A government-monopsony market is a model where the government is the sole buyer, and kidneys are distributed according to need, not ability to pay. The framework of collective duties enables us to respond to several of the most pressing ethical and practical objections to kidney markets, including Cécile Fabre's objection that it is unjust to be paid to do one's duty, Simon Rippon's objections that it is harmful to be pressured to sell a kidney and that a market is unfair, Richard Titmuss's crowding out objection, and Ronald Dworkin's objection that body parts should not be among the goods we owe each other.

"By prohibiting monetary compensation, it has been objected that the government takes advantage of people who feel compelled to save someone close to them. Receiving a kidney may also come with a price, a price compounded by how kidney donations are framed within the current system: as priceless gifts and extraordinary acts of sacrifice. When kidney donations are seen in this way, they may impose a burden of gratitude on the recipient; recipients may feel they can never repay such priceless gifts. ‘The tyranny of the gift’ challenges the donor and recipient's equal standing.

...

"Several authors, most notably Charles Erin and John Harris, have defended a government-monopsony model. My primary contribution is to present a novel defence of this model. I argue we have collective duties to provide the sick with kidneys and derivative duties to pay donors. This view provides us with resources to respond to many of the most compelling ethical objections to kidney markets."

Congestion in applications and interviews, by Arnosti, Johari and Kanoria

 Here's a paper modeling the issue that some labor markets may face congestion related to large numbers of applications followed by costly interviews.

Nick Arnosti, Ramesh Johari, Yash Kanoria (2021) Managing Congestion in Matching Markets. Manufacturing & Service Operations Management 23(3):620-636. https://doi.org/10.1287/msom.2020.0927

Abstract. "Problem definition: Participants in matching markets face search and screening costs when seeking a match. We study how platform design can reduce the effort required to find a suitable partner. Practical/academic relevance: The success of matching platforms requires designs that minimize search effort and facilitate efficient market clearing.

"Methodology: We study a game-theoretic model in which “applicants” and “employers” pay costs to search and screen. An important feature of our model is that both sides may waste effort: Some applications are never screened, and employers screen applicants who may have already matched. We prove existence and uniqueness of equilibrium and characterize welfare for participants on both sides of the market. Results: We identify that the market operates in one of two regimes: It is either screening-limited or application-limited. In screening-limited markets, employer welfare is low, and some employers choose not to participate. This occurs when application costs are low and there are enough employers that most applicants match, implying that many screened applicants are unavailable. In application-limited markets, applicants face a “tragedy of the commons” and send many applications that are never read. The resulting inefficiency is worst when there is a shortage of employers. We show that simple interventions—such as limiting the number of applications that an individual can send, making it more costly to apply, or setting an appropriate market-wide wage—can significantly improve the welfare of agents on one or both sides of the market. 

"Managerial implications: Our results suggest that platforms cannot focus exclusively on attracting participants and making it easy to contact potential match partners. A good user experience requires that participants not waste effort considering possibilities that are unlikely to be available. The operational interventions we study alleviate congestion by ensuring that potential match partners are likely to be available.

And from the Conclusion:

"We also compare the effects of an application limit to those of other available levers: either raising application costs or lowering the wage paid to applicants. Although these interventions can lead to thesame aggregate welfare as an application limit, they differ in how they distribute this welfare. Charging fees and lowering wages both increase aggregate welfare at the expense of applicants. Although these interventions may be appropriate for a platform looking to monetize its services or attract more employers, an application limit can yield Pareto improvements in welfare and may be more suitable if the platform is primarily concerned with applicant welfare. These considerations might explain why the tutoring platform TutorZ charges tutors for each potential client that they contact, whereas the dating platforms Coffee Meets Bagel and Tinder limit the number of likes/right swipes permitted in a certain period."

Congestion in interviews for pediatric surgery fellowships

 In recent years, pediatric surgery has been a very popular subspecialty among Stanford surgical residents (upon completion of their 5 year general surgery residency).  A lot of time and treasure is spent interviewing for these relatively few fellowship positions: except in 2020 when interviews were remote, fellowship applicants pay for their own travel, etc.  And Stanford hospitals pull back on elective surgeries while the surgical residents are on the road interviewing.  Is so much interviewing inefficient?  Many think so, and here are some data.

Analysis of the pediatric surgery fellowship application process using the Thalamus™ database, by  Saunders Lin, Jason Reminick, Ephy Love, Benedict Nwomeh, Sanjay Krishnaswami, Journal of Pediatric Surgery, Volume 56, Issue 6, June 2021, Pages 1095-1100

"Background: The pediatric surgery fellowship interview process is costly and time intensive. We hypothesized that the increasing number of interviews completed by applicants and programs have become inefficient over time.

...

"Results: Our dataset included 34, 41, and 45 programs, which represented 81%, 91%, and 97% of all programs in 2018, 2019, and 2020, respectively. The median number of interviews completed per program remained constant, while the median number of interviews per applicant increased from 9.0 in 2018 to 13.0 in 2020. For 75% of programs, a program required only 4 or less candidates to fill their position. On average, 96% of program interviews do not result in a matched candidate.

"Conclusions: Programs offer interviews out of proportion to the number of positions available, and most applicants attend all interviews offered. We recommend an initial program goal of 20 interviews, which may be achieved by increased use of virtual interviews and the creation of program-level data on ideal applicant profiles.

...

"1. Introduction: With the advent of computer scheduling software and electronic interview platforms, data collection regarding the pediatric surgery fellowship interview process on a national level is now possible. One such platform is Thalamus, a scheduling software currently used for pediatric surgery fellowship interviews [1].

"The pediatric surgery match remains one of the most competitive fellowship application processes, with a total of 43 available positions for 78 applicants in the 2020 match cycle [2]. Published data show that extensive time and monetary resources are used every applicant cycle, with the average candidate spending around 14% of pretax salary and using up to three full weeks of residency days to complete interviews [3]. Despite these costs, however, programs continue to place considerable value on in-person interviews.

...

"2.1. Data source and methods: Thalamus is a comprehensive online and mobile Graduate Medical Education (GME) scheduling and communication software currently used in the pediatric surgery interview process. For applicants, features include a real-time scheduling system with online and mobile compatibility that allows applicants to self-schedule and instantly confirm their interview dates. From a program perspective, Thalamus is able to handle all interview confirmations, cancellations and rescheduling, and allows for comprehensive collection of applicant and program data both on the aggregate and individual levels.

"Thalamus was founded in 2013 and has been used in pediatric surgery since December 2016. The software is also currently used by more than 2200 residency and fellowship programs at more than 200 hospital systems across more than 100 specialties. It segments each institution by institutional ID and each program within each institution by program + ACGME ID (or a similar number for non-ACGME accredited programs). This is a cloud hosted database on the Microsoft Azure/SQL Server. Thalamus maintains several IRB approved/exempt research relationships with various specialties and other leadership organizations in Graduate Medical Education. This data is not shared between programs nor any other organization outside of Thalamus.

"We performed a retrospective investigation using Thalamus to identify population-level parameters regarding the pediatric surgery match between 2018 and 2020. This study was deemed exempt from approval by the Oregon Health and Sciences University Institutional Review Board as it did not contain patient data and applicant data was de-identified.

"3.2. Individual program and applicant data: With regards to individual program and applicant match data, the mean number of interviews offered and completed per program were similar in all three years (Table 2). The highest number of interviews a program completed was 44 in 2020. The number of interviews offered and completed per program have remained constant during the time-period. In contrast, both the mean and median number of interviews received and completed by applicants have increased. The median number of interviews completed per applicant increased 33.3% between 2018 and 2019 and an additional 12.5% between 2019 and 2020. Furthermore, the number of applicants who complete three or less interviews have been decreasing in the past three years: 25% in 2018, 20.6% in 2019, and 11.4% in 2020. Conversely, the number of applicants who completed more than 20 interviews has also been increasing in the past three years.

Matching Teach For America Teachers to Schools, by Jonathan Davis

Some years ago Clayton Featherstone and I worked with Teach for America to design their process for matching new recruits to school districts.  Now here's a paper on the next step in the assignment process: matching teachers to particular schools.

Labor Market Design Can Improve Match Outcomes: Evidence from Matching Teach For America Teachers to Schools   by Jonathan M.V. Davis

Abstract: "I worked with Teach For America (TFA) to match high school teachers to schools in Chicago using the deferred acceptance algorithm (DA), while keeping its original mechanism unchanged for elementary teachers. Comparing actual matches under DA to simulated counterfactual matches suggests half of teachers strictly prefer their matches under DA and very few teachers are worse off. This improved matching yields longer-run benefits: matching with DA increased teachers retention through their two-year commitment to TFA by between 6 and 12 percent. This provides empirical support for the hypothesis that economic design can improve match outcomes in labor markets without negotiable wages. "

"Before I began working with TFA, interview day matches were determined by what I will refer to as the First Offer Mechanism (FO). This mechanism works as follows:

"Step 1. Complete round 1 interviews. After completing the round 1 interview, each school decides whether to make an offer to the teacher they interviewed. If given an offer, the teacher must accept it or exit Teach For America.

"Step 2 ≤ k ≤ K. Complete round k interviews involving unhired teachers. Each school decides whether to make an offer to the teacher they interviewed. If given an offer, the teacher must accept it or exit Teach For America.

...

"In fall 2013, I contacted TFA and suggested that they may benefit from replacing FO with DA. Given TFA’s policy that teachers accept their first offer and the organizational value that “TFA teachers go wherever they are needed”, the school position proposing version of DA was selected. In order to credibly identify the impact of the change, I worked with TFA to initially implement DA at its high school interview days for its 2014 cohort. This cohort was admitted to TFA in early 2014 and committed to teaching with TFA during the 2014-15 and 2015-16 school years. They continued using FO at the elementary interview days for this cohort."

Help for Danish kidney-exchange pairs, from a private foundation (while waiting for the health care system to cover international exchange)

 Yesterday I blogged about a particular global kidney exchange in which a Danish pair joined an American kidney exchange chain. Among the obstacles to be overcome were some of a financial nature: the Danish healthcare system declined to pay for a transplant outside of Denmark, even though no compatible kidney had been found in Denmark after several years of waiting.

The first part of the good news is that both the patient and donor are thriving, back home in Denmark.  The second part of the good news is that a private Danish foundation has stepped forward to help bridge some of the financial obstacles.

Mike Rees writes to me as follows:

"A Go Fund Me-type campaign in Denmark was initiated by a Newspaper advertisement placed by Claus Walther Jensen. Many small donations later, and a large donation from a wealthy businessman, Niels Due Jensen, himself a kidney transplant recipient, helped pay for Natacha’s transplant and associated expenses to come to the US. The APKD subsidized about $40,000 of their costs—including the donor’s lost wages, travel expenses, etc. After seeing the success, Niels Due Jensen established a fund with 5M Kroner per year for five years to support GKE for Danish citizens who cannot match in Scandinavia. See: https://www.ndjaf.dk/ ." 

The page opens with the story that was the subject of yesterday's blog:

"13 people died in 2019 on the waiting list for a new kidney in Denmark. In addition, 47 people were permanently removed from the waiting list because they had become too ill to receive a new kidney.

"This is because we in Denmark and Scandinavia have a fundamental shortage of donor kidneys. 

Natacha is one of the patients who should still have been on the waiting list if it was up to the Danish healthcare system. In the United States, a matching kidney was found in less than 2 hours."

****

The site goes on to tell the larger story:

"Do we have a well-functioning kidney exchange system in Denmark?

...

"In Denmark, we are not skilled enough to optimize the supply of donor kidneys, which is partly due to the fact that we do not utilize the full potential of close friends and family who want to donate a kidney to their loved ones. This is because a donor kidney must "match" the recipient's tissue type and blood type in order for the recipient to benefit from the donor kidney.

"There will on average be a match for approx. 70% of cases, which means that in 30% of cases the donor does not have the opportunity to donate, which is a big waste - which can be partially avoided!

"For almost 20 years, so-called "kidney exchange systems" have existed abroad, which allow non-matching donors to indirectly help their loved ones, by donating to a pool (and thus to another person) so that one's loved ones in return receive a matching donor kidney from the same pool. With this, there are 2 or more "pairs" who exchange donor kidneys, so that all patients get a kidney that suits them.

"In Scandinavia, a "kidney exchange system" has now also been made, which is a major step forward. However, the system is not as efficient as in the USA, for example, where the pools of donor kidneys are much larger and thus also much more efficient. The system in the USA can therefore help those patients who cannot be helped via the Scandinavian system.

"So far, the Regions and doctors have chosen not to inform the Danish kidney patients about this possibility. In addition, Region H has in two cases refused to pay for Danish kidney patients who have been part of the kidney exchange system in the USA to have a transplant performed in the USA. The cost is approx. DKK 800,000 pr. person. The two patients have had the transplants completed in the USA by self-payment and collection from benevolent Danes, respectively. Both patients are well-functioning today and make a positive contribution to Danish society."

*******

And, to get to the point:

"Niels Due Jensen's non-profit foundation works to ensure that the Danish hospital system offers Danish kidney patients, approved for kidney transplantation in Denmark, who have a non-matching donor kidney, also approved for transplantation in Denmark, that they can be offered to join a foreign kidney exchange system and that the state will bear the costs associated with a transplant abroad. Of course, provided that the patient in question does not receive or is expected to be able to receive a donor kidney in Denmark within a reasonable time (one year).

"Until the Danish kidney patients get this right, Niels Due Jensen's non-profit foundation will donate up to 5 million every year DKK, to support people residing in Denmark who, based on an overall assessment of their own financial resources and health condition, have an urgent need for costly treatment for kidney transplantation, and possibly, for a transitional period, support the individual patient's convalescence."

I salute Mr. Jensen, and I look forward to the day when global kidney exchange will be a standard part of medical care to address the global problem of kidney failure.

Global kidney exchange with Denmark, in the U.S.

A Danish citizen with a willing but incompatible living donor, received a kidney exchange transplant in the U.S., through the Alliance for Paired Kidney Donation (APKD).

Denmark is a wealthy country that has good health care for its citizens. ScandiaTransplant has recently started kidney exchange.  But there wasn't a match there for this incompatible pair. Fortunately for them they encountered Susan and Mike Rees, who were in Copenhagen for a transplant conference.

But Danish health insurance couldn't find a will and a way to pay for the transplant in the U.S., so there were still financial barriers that had to be overcome. About two thirds of the needed funds were raised from private donations in Denmark, and about a third was covered by the AKPD.

ABC news first reported the story:

Chance meeting at bus stop in Denmark saves many lives 

"Natacha Kragesteen, 28, was born with a genetic defect that eventually led to her need for a life-saving kidney transplant. She lives in Denmark with her two young daughters and her boyfriend Louis Plesner.

"Louis wanted to donate a kidney to Natacha, but he was not a match. That left her on the kidney transplant waiting list for the last few years and undergoing kidney dialysis three times a week for four hours a day.

...

"The couple connected with Susan, who is a registered nurse, and Mike, who is a kidney transplant surgeon, and came to the conclusion that they would be helped in Toledo in the paired kidney exchange.

...

"The life-saving chain wouldn't just help the young couple. Louis's kidney would be flown down to Wake Forest University in North Carolina to help someone there, and the donor from Wake Forest donated a kidney to someone at Duke University. The Duke donor's kidney came to Toledo to save Natacha's life.

"In addition to this life-saving chain, the Minister of Health from Denmark is now considering opening that country to the paired kidney exchange program so that other people waiting for kidney transplants have a greater chance of getting one.

"So a chance meeting at a bus stop has the potential to save thousands of lives."

***********

And here's an article from the Danish press (and Google Translate):

Mine børn fortjener en rask mor ["My kids deserve a healthy mom"]

"After almost three years in treatment, the miracle happened. Louis was on a trip to Copenhagen and was waiting for a bus when he fell into conversation with two Americans at the stop.

"It turned out that they were researchers from Johns Hopkins Hospital in the USA, and that they had just been to a kidney conference in the Danish capital. 

"Louis told them about his girlfriend's situation, and they immediately offered their help. The two researchers knew the renowned kidney surgeon Michael Rees, who is behind a successful kidney exchange program in the United States.

...

" It was completely surreal when he showed up at the hospital. He explained to us about his kidney exchange program, where a kidney patient and a willing donor who unfortunately do not fit together are matched with other couples in the same situation. That way Louis could donate his kidney to a foreign patient who would then have his own donor ready who could donate a kidney to me. Several pairs could also be included in such a kidney exchange chain so that all kidney patients would get a kidney that fit them perfectly.

"A similar kidney exchange program exists in Scandinavia, but it would not have been possible for Natacha to find a kidney through this system due to the relatively small pool of donor pairs and Natacha's many antibodies.

" So I decided to give the American program a try, and Michael Rees took blood samples from both me and Louis home to the United States and ran them through his system. A few hours later, he had found six potential donors for me. I felt it was almost too good to be true.

"Maybe it was too. The operation cost 800,000 kroner, and like most others, Natacha and her family were nowhere near being able to pay the amount out of their own pocket. When they applied for financial help from the Danish state, they were rejected.

...

"Natacha refused to give up, however, and with the help of the businessman Claus Walther Jensen, who himself has kidney disease in the family and therefore has also had contact with Michael Rees, she started a fundraising campaign, where she via Facebook posts, newspaper articles and the website savenatacha.dk explained his situation and appealed to the support of the people. 

...

"On February 2, Natacha and Louis left for the United States to undergo their kidney surgery, which was to take place 11 days later at Toledo University in Ohio and performed by Michael Rees. Meanwhile, their two daughters were cared for by their grandparents back home in Denmark.

...

"Louis' operation did not go exactly as planned. During the operation, a vein ruptured and he was about to bleed on the operating table.

"The doctors therefore had to open him up completely to stop the bleeding, so he ended up getting a giant scar on his stomach instead of the expected three small scars where the kidney was taken out. 

...

"Nor did Natacha's operation go exactly as hoped. Shortly after the transplant, it turned out that the new kidney was not getting enough blood, so the doctors had to take it out again and try to angle it differently. It helped with the blood flow, but when Natacha subsequently started bleeding inside, she had to have surgery for the third time in  a few days.

...

"Today, Natacha is feeling better than she has been for many years. She takes immunosuppressive medication so that her body does not attack the new kidney, and is monitored regularly by the Danish healthcare system. But the time of countless hospitalizations and dialysis treatments is over.

...

"Natacha hopes that her story can raise awareness of the benefits of a kidney exchange program, and that in the future it will be easier for Danish kidney patients to have surgery abroad."

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

A Danish television broadcast in two parts is here (in Danish):

 

Jagten på en nyre [Hunt for a kidney]

***********

One of the issues in Global Kidney Exchange is covering not only the initial costs of patients and donors who aren't insured in the U.S., but also arranging for insurance in case of complications.  This story gives some insight into the kinds of complications that can arise, even if only rarely.  Part of the market design issue is how to cover these costs in a systematic rather than an ad hoc way.  In the present case, the costs of caring for the donor and recipient when they returned home was taken care of by the Danish healthcare system, even though  it had declined to help with the transplant in the U.S.

I'll post tomorrow about how some of this challenge is being met in Denmark, for the time being, by a newly formed private foundation.

It's time to allow kidney exchange in Germany: Axel Ockenfels in the Handelsblatt

 As I noted last month, there's a conclave on kidney transplantation at the end of June in Germany. Axel Ockenfels keeps the focus on kidney exchange, in the Handelsblatt:

Die Regeln für Organspenden in Deutschland sollten reformiert werden

Google Translate: "The rules for organ donation in Germany should be reformed.

In the Federal Republic of Germany only close relatives can be considered as living organ donors. This is unnecessarily restrictive, thinks Axel Ockenfels and promotes cross-donations."

...

"In Germany, the necessary reforms for cross-donation can be accomplished within the current value framework, which presupposes the voluntary and altruistic nature of organ donation. Organ trafficking can be reliably excluded through institutional arrangements.

In a new survey, cross-donation receives great approval, both in Germany, where it is still prohibited, and in countries where it is permitted. There is much to be said for reform."

***********

Here's a link to a (the?) survey of attitudes in Germany and elsewhere:

Thursday, July 30, 2020

Surrogacy and global kidney exchange receive popular support even where banned, in PNAS by Roth and Wang

Advice for setting up a kidney exchange program

 Advice from Italian doctors, on living kidney donation including kidney exchange, in the one year old journal Transplantology:

Living Kidney Donation: Practical Considerations on Setting Up a Program, by Maria Irene Bellini, Vito Cantisani 3, Augusto Lauro, and Vito D’Andrea, Transplantology 2021, 2(1), 75-86; https://doi.org/10.3390/transplantology2010008 

Abstract: Living kidney donation represents the best treatment for end stage renal disease patients, with the potentiality to pre-emptively address kidney failure and significantly expand the organ pool. Unfortunately, there is still limited knowledge about this underutilized resource. The present review aims to describe the general principles for the establishment, organization, and oversight of a successful living kidney transplantation program, highlighting recommendation for good practice and the work up of donor selection, in view of potential short- and long-terms risks, as well as the additional value of kidney paired exchange programs. The need for donor registries is also discussed, as well as the importance of lifelong follow up.

"The participation of a large number of transplant centers is vital to maximise the chances to achieve better human leucocyte antigen (HLA) or age match, thus it is envisaged that even compatible pairs for their recipients are involved, in order to generate more exchange opportunities. In view of the better outcomes, it is also recommended to include HLA incompatible (HLAi) pairs in preference to antibody removal, as well as ABO incompatible (ABOi) pairs to avoid the costs and higher risks associated with desensitization programs, or at least by registering them for a number of runs in the KPD before choosing these alternative treatments [7]. This applies specifically to children, where getting a well-matched kidney as early as possible is fundamental to preserve the long-term outcome, reducing the chances of sensitisation and being dialysis-dependent in the future to the minimum.

"Other effective ways to implement KPD are the inclusion of altruistic (unspecified) donors to trigger KPD chains; multiple registrations of potential donors for a single candidate; and the extension of the length of the exchanges, potentially also considering deceased donor kidneys as chain-initiating kidneys [8]."

Realtors still have a few tricks up their sleeves--"Whisper listings"

 It once looked as if the growth of the internet, and increased access to home listing databases, would substantially weaken the grip of licensed Realtors on the residential housing market in the U.S. Those predictions proved premature: Realtors have kept a very large market share, while earning high fees as prices rise (based on a percentage of the sales price).  

The WSJ has part of the ongoing story:

In Tight Housing Market, Thousands of Homes Are Reserved for Certain Buyers. ‘Whisper listings,’ made directly to select customers, are growing at a time when housing inventory is near record lows  By Nicole Friedman

"In the vast majority of transactions, an agent lists a home for sale on a local database and markets the property widely to drum up interest and get the best price. But in certain cases, a broker will show an unlisted property to a small circle of potential buyers more exclusively, often in hope of getting a deal done quickly.

"These private sales are known as pocket listings, or whisper listings. They have been around for many years. But they are on the rise now even though the National Association of Realtors adopted a rule last year aimed at discouraging their use following complaints from some of its members.

"The new NAR policy requires agents to add listings to their local database within a business day of publicly advertising the listing. But there is a notable exemption: Listings can still be kept off the database if they are only shared within one brokerage, called an “office exclusive.”

Strategic issues with (combined) early and late matching, by Mumcu and Saglam

  Here's a paper on early decision in college admissions. I read it with particular interest because of related discussions going on right now about early and late matching to medical residencies in the U.S. In their model, early matching introduces either or both strategic behavior and instabilities.

Strategic Issues in College Admissions with Early Decision by Ayse Mumcu and Ismail Saglam, Economics Bulletin, Volume 41, Issue 1, 2021

Abstract: In this paper, we consider college admissions with early decision (ED) using a many-to-one matching model with two periods. As in reality, each student commits to only one college in the ED period and agrees to enroll if admitted. Under responsive and consistent preferences for both colleges and students, we show that there exists no stable matching system, consisting of ED and regular decision (RD) matching rules, which is nonmanipulable via ED quotas by colleges or ED preferences by colleges or students. We also show that when colleges or students have common preferences and each student applies early only to the top-ranked college with respect to her RD preference, then no college has a strict incentive to offer a single-choice ED program. On the other hand, if students compromise in the ED market and make early application to colleges that are not top-ranked, then colleges may become better off when they offer ED programs than when they do not.

Domestic and foreign medical residents in the U.S.

 From the Health Affairs blog:

Graduate Medical Education Positions And Physician Supply Continue To Increase: Implications Of The 2021 Residency Match  by Edward S. Salsberg Candice Chen

"With the merger of the Accreditation Commission for Graduate Medical Education (ACGME) and the American Osteopathic Association (AOA) accreditation system between 2015 and 2020, the “NRMP Main Match” now covers an estimated 96 percent of the physicians entering GME in the US. This post looks at some of the major takeaways from the 2021 NRMP Match including the implications for the physician workforce.

"Serious concerns have been expressed that there are too few residency training positions in the US and that this is contributing to a gap between the number of medical school graduates and the number of training slots, often referred to as the “GME squeeze,” and that this shortage of residency positions is also contributing to a potential future physician shortage. In 2020, the Association of American Medical Colleges (AAMC) released their annual report projecting primary and non-primary care physician shortages between 55,100 and 141,900 physicians over the next decade.

...

"In this piece, we focus on the 35,194 first-year positions offered in the 2021 Match, and the 26,967 US MD and DO seniors actively participating in the Match for a first-year position.  

...

"Key Takeaways

"The Number Of Entry GME Positions Continues To Grow 

"There were 35,194 first-year positions offered in the 2021 Main Residency Match representing an increase of 2.7 percent from 2020. Comparing the combined number of ACGME- and AOA-accredited first-year positions in 2013 with the 2021 data indicates a 24.5 percent increase in positions over the eight years for an annual increase of 2.8 percent (exhibit 1). The net increase of 6,930 first-year positions over such a short period will be surprising to many given the absence of a major new federal funding initiative or change in GME policy.

...

"There Are No Signs Of A Major GME Squeeze For US MD And DO Seniors

"The number of new first-year GME positions is growing more rapidly than the annual number of graduating US medical school seniors. As noted above, the number of first-year positions grew by 6,930 positions at a 2.8 percent annual rate between 2013 and 2021.

...

"International Medical Graduates Continue To Be A Major Source Of Residents And Physicians For America 

In 2021, there were 13,238 active IMG applicants in the NRMP Match of which 7,508 IMGs were matched to first-year positions (excluding SOAP). Overall, IMGs represented 22.5 percent of all applicants who matched to first-year positions. IMGs include two very different cohorts: US IMGs, US citizens who have gone to medical school outside of the US, mostly at for-profit schools in the Caribbean; and non-US citizens who attended medical school in a foreign country, usually their home country.

...

"The numbers of both types of IMGs matched in the Main Match has been increasing slowly (exhibit 2), with 4,356 non-US IMGs and 3,152 US IMGs matching to first-year positions in 2021 (excluding SOAP). Interestingly, while the number matched went up 22.5 percent for non-US IMGs and 17.1 percent for US IMGs between 2013 and 2021, the number of active applicants was more consistent, rising only 5.0 percent and 3.9 percent over the same time period for each group."

Covid vaccine congestion in France looks familiar

France is some weeks behind the U.S. in delivering vaccines, but the script will look familiar to Americans.

The  Financial Times has the story:

France finally gets its Covid vaccination act together. The country’s inoculation drive has picked up speed after a slow start. by David Keohane 

"All it took to get my first dose of the Covid-19 vaccine in France was a five-hour round trip and two days and eight hours of incessant refreshing at my computer. 

...

""Until May 12, younger people in France weren’t allowed to book a vaccination unless they suffered from an underlying health condition which pushed them up the queue. 

"Since then anyone can book as long as the dose is set to go begging in the following 24 hours."

Vaccinating the whole world quickly turns out to be hard

 As Covid vaccines became available, rich countries that had made early, advanced purchases at high prices had contracts that delivered available doses early, while countries and organizations that had made later purchases at lower prices had "best effort" contracts that allowed delivery dates to slip as supply chain problems developed.  The consequences were greatest for the poorest countries, despite efforts to speed vaccination worldwide.

The WSJ has the story:

Why a Grand Plan to Vaccinate the World Against Covid Unraveled. The multibillion-dollar Covax program was supposed to be a model for vaccinating humanity, but has hit problem after problem By Gabriele Steinhauser, Drew Hinshaw and Betsy McKay

"The Covax program, conceived in early 2020 as a kind of Operation Warp Speed for the globe, was supposed to be a model for how to vaccinate humanity, starting with those who needed it the most. The plan was scheduled to have the developing world’s entire healthcare workforce immunized by now.

"Instead, the idealistic undertaking to inoculate nearly a billion people collided with reality, foiled by a basic instinct for nations to put their own populations first, and a shortage of manufacturing capacity around the world.

"Dr. Berkley and a small crew of global health experts spent months trying to recruit much of the world into buying their vaccines from one common pool, rich and poor countries alike. While they were hammering out the details and raising money, nations that could afford it rushed to secure their own shots first.

...

"Most of the world’s poorest nations were left highly dependent on a single vaccine, produced by a single manufacturer in a single country. In a cruel twist, that supplier—the Serum Institute of India—ended up engulfed by the world’s worst Covid-19 outbreak.

...

"Dr. Berkley, the chief executive of Gavi, the Vaccine Alliance, a public-private partnership that secures childhood immunizations for the world’s poorest countries and is the central organization behind Covax, said the facility did its best to navigate a hypercompetitive vaccine market. “We hear a lot of criticism, and the truth is, we’ve tried to do something that we think is the right thing,” he said. “Hindsight’s 2020. Should we have not invested in India? Well, that was the fastest way to get there.”

...

"Covax started shipping Covid-19 vaccines within three months of the world’s richest countries administering their first shots—lightning speed, compared with the five to 10 years it often takes for new immunizations to reach the developing world.

"Yet now it is running out of vaccines just when Covid-19 cases are escalating across countries it was meant to protect: the low- and middle-income states of Latin America and South Asia. The program has shipped 72 million shots, far short of the 238 million it had targeted by the end of May. That’s 4% of the total 1.7 billion vaccines shipped world-wide.

"Some 20 million of Covax’s shots have come from India, which was due to ship 140 million by the end of the month but stopped exporting them as it works to inoculate the country’s 1.3 billion citizens

...

"Wealthy countries, including ones that had promised to fund Covax, were buying their own doses first. In late May, the U.K. had sealed its own agreement with AstraZeneca, for 100 million doses. The U.S., without a commitment to Covax, had signed up for 300 million from AstraZeneca, pledging up to $1.2 billion.

"In June, the European Union, worried that its own countries would start competing for limited supply, stepped in to buy shots for its 450 million citizens. As part of its deal with member states, the EU blocked governments from joining any parallel vaccine purchasing programs. That meant France and Germany were now effectively barred from buying doses from the pool they had championed.

...

"By late December, after months of haggling over prices, Covax had 2 billion doses lined up, enough to vaccinate some 20% of the population in over 100 countries. Yet most were soft agreements with no clear delivery dates or involved drugmakers whose shots hadn’t yet panned out. As Europe and the U.S. began to vaccinate, Covax’s only completed purchases were with AstraZeneca and the Serum Institute.

...

"On Feb. 15, the WHO approved the AstraZeneca shot for emergency use, six weeks after it was cleared in the U.K. That allowed Covax to make its first shipment to a developing country, Ghana, weeks after Serum began exporting shots to other countries.

"Three days later, the U.S., now under President Biden, announced a $2 billion contribution to Covax, with another $2 billion planned through 2022. The EU upped its commitment to 1 billion euro.

"By then, there were scant vaccines available to buy. This month, Covax reached a deal with Moderna for 500 million doses, of which 466 million won’t be delivered until 2022."

Conference on Equity and Access in Algorithms, Mechanisms, and Optimization (EAAMO ’21), Oct. 5-9 2021

 "The inaugural ACM conference on Equity and Access in Algorithms, Mechanisms, and Optimization (EAAMO ’21) aims to highlight work where techniques from algorithms, optimization, and mechanism design, along with insights from the social sciences and humanistic studies, can help improve equity and access to opportunity for historically disadvantaged and underserved communities. The conference will provide an international forum for presenting research papers, problem pitches, survey and position papers, new datasets, and software demonstrations towards the goal of bridging research and practice. Read more about us below.

The deadline has been extended to June 14th, 5pm ET / 9 pm GMT.

EAAMO ‘21 is organized by the Mechanism Design for Social Good (MD4SG) initiative, and builds on the MD4SG technical workshop series and tutorials at conferences including ACM EC, ACM COMPASS, ACM FAccT and WINE. The conference will feature keynote talks, panels, and contributed presentations across numerous fields. In line with the MD4SG core values of bridging research and practice, the conference will bring together researchers, policy-makers, and practitioners in various government and non-government organizations, community organizations, and industry to build multi-disciplinary pipelines."

More info, including submission details here.

Kidney to Share book launch, Zoom recording

 Last week I had the pleasure of joining the discussion of the book Kidney to Share  by Martha Gurshun & John Lantos.  It was on Zoom, and the recording is now available here.

Martha and John speak for the first half hour, then I make some remarks for about ten minutes, after which there is an interesting general discussion. The whole thing is an hour, and the recording allows you to hear it at 1x, 1.5x or 2x the original speed...

Alejandro Martínez-Marquina defends his dissertation

 Alejandro Martínez-Marquina defended his dissertation this week.

 The three papers he chose for his dissertation are these:

When a Town Wins the Lottery: Evidence from Spain

(with Christina Kent) [Slides] [Draft]

"How do local wealth shocks impact economic activity? For over two centuries, Spain has conducted a national lottery which often results in the random allocation of up to $800 million in cash to the citizens of one town. This is the only case in the world where individuals living in the same location randomly receive pure wealth shocks of this scale. Leveraging data on town-level lottery ticket expenditures, we compare winning towns to non-winning towns that had the same probability of winning. We find that although consumption increases, the lottery causes a slowdown in economic activity and deters new migration to towns that won in recent decades. However, an analysis of a century of lottery winners reveals large and persistent increases in population for towns that won in earlier periods."

The Burden of Household Debt

(with Mike Shi)

"We propose that holding debt causes worse financial decisions using a novel experimental design where we randomly assign debt. Our design isolates the consequences of holding debt while controlling for potential confounding factors such as initial wealth levels, selection, risk, and time preferences. Our findings show that debt causes behavioral biases detrimental to subjects' financial payoffs. However, subjects' strategies are not random but instead debt-biased, consistent with an additional penalty for holding negative balances. We refer to the financial losses caused by debt as the Burden of Debt and provide evidence that, under certain circumstances, these behavioral biases can compound and lead to substantial losses. Furthermore, we show in additional treatments how these debt-biased behaviors can also deter subjects from borrowing and forego profitable opportunities."

Ingraining Traditional Gender Roles in the Classroom: Evidence from the Spanish Social Service

[Slides]

"This study uses a regression discontinuity framework to examine the long- run effects of conservative education on women's' family and labor decisions. In 1939, the Spanish dictatorship created the Social service, a compulsory 6- month training program aimed at relegating women to the roles of mothers and housewives. We exploit the discontinuity induced by the sudden abolition of the Social Service, in addition to variation in the age of enrollment, to examine the consequences of attending the program. Using historical enrollment records and the universe of birth certificates, we find the Social Service was successful in instilling the regime's ideology. Women exposed to the class get married and have kids at younger ages, consistent with the desire to form a family sooner. In addition, they are more likely to declare being housewives when their first child is born. Future work will explore the underlying mechanisms and the effects on children by surveying women who enrolled around abolition."

Welcome to the club, Alejandro.

Aleandro ( top center) with Chenzi Xu, Muriel Niederle, Doug Bernheim, Al Roth, Ran Abramitzky

The internet hybrid of pornography and sex work on OnlyFans

 Sex work is mostly  about in-person, one-on-one, personal encounters.  Pornography is mostly about publishing, whether in print or other media, so it is mostly about trying to reach a wider audience (even if a specialized one).  The internet has given birth to something in between, as exemplified by OnlyFans, a site that allows online communication of a sexual sort to be personalized, via individual subscriptions to personalized content, or micro-subscriptions to particular, paywall protected content. (The motto on their front page reads "Sign up to make money and interact with your fans!")  It grew a lot during the pandemic.

The NY Times has a story that likens it to a strip show with private rooms, in which the show on center stage is an invitation for fans and performers to interact more privately. Star performers can make real money, although most performers aren't stars.  

OnlyFans Isn’t Just Porn  By Charlotte Shane

"OnlyFans was founded in 2016, though its bland design makes it look like a relic from an older era. Its interface isn’t attractive, but it is familiar and easy to navigate, like a pared-down, browser-based version of Instagram or Twitter. (An OnlyFans smartphone app does not currently exist; it wouldn’t be allowed on the App Store or Google Play because of its X-rated content.) In December 2019, the platform had a user base of 17 million, which means that at some point during the pandemic, it started averaging as many new registrations per month as it had in a previous year.

...

"Though OnlyFans’ representatives seem to distance the site from its sexual content, the platform is synonymous with porn. Its naughty cachet attracts celebrities, whose presence on the site garners a disproportionate amount of attention. When Cardi B joined last August, she made headlines. (“No, I’m not going to be showing my titties,” she warned, but she did promise behind-the-scenes content from her risqué “WAP” music video with Megan Thee Stallion.) Celebrities use the site because they know that regardless of a creator’s stated career (chef, fitness trainer and influencer are popular), OnlyFans’ draw is the promise of seeing that which is normally unseen. 

...

"In this virtual strip club, as in the brick-and-mortar club, there are wide discrepancies in pay. Some performers leave with $100, while other hustlers go home with ten times as much. Established porn stars who before the pandemic could rake in thousands per night by appearing as a strip joint’s “featured dancer” enjoy a similar, even more lucrative power on OnlyFans. 

...

"“OnlyFans is buying houses for girls,” she told me. “It is supporting sex workers’ families. It’s everything that people are saying.” But like the misleading caption used to sell a celebrity’s locked posts, what people say can be accurate while failing to tell the truth.

...

"OnlyFans was perfectly positioned to become a housebound population’s go-to source for explicit material because of what is called the gentrification of the internet. In the context of sex work, this refers to an aggressive pattern of policing both the sex trade and the people who work in it.

"In the United States, this regulatory campaign can be traced back to the federal government’s protracted and ultimately successful crusade against Craigslist’s Erotic Services in the early 2010s. Since then, the F.B.I. and federal prosecutors have systematically targeted a slew of sites that cater to sex workers, particularly advertising platforms like Backpage, which shuttered in 2018 after a multiyear effort by California’s attorney general at the time, Kamala Harris. In April that year, the bills known collectively as FOSTA-SESTA, which further criminalize communication around commercial sex, were signed into law by Donald Trump.

Payments for Covid vaccine

 The NY Times has the story:

Pakistan’s Private Vaccine Sales Highlight Rich-Poor Divide.  An inoculation push, plagued with limited supplies and red tape, makes doses available to those who can pay for them. In a country with a struggling economy, most can’t.  By Salman Masood

"Access to the coronavirus vaccine has thrown a stark light on global inequality. The United States and other rich countries have bought up most of the world’s vaccine supplies to protect their own people, leaving millions of doses stockpiled and in some places unused. Less developed countries scramble over what’s left.

"To speed up vaccinations, some countries have allowed doses to be sold privately. But those campaigns have been troubled by supply issues and by complaints that they simply reflect the global disparities.

...

"“The Pakistani example is a microcosm of what has gone wrong with the global response — where wealth alone has primarily shaped who gets access,” Zain Rizvi, an expert on medicine access at Public Citizen, a Washington, D.C., advocacy group, said in an email.

...

India sells vaccines to private hospitals, though they are scrambling to find supplies now that the pandemic there is so serious. Kenya authorized private sales, then blocked them over fears that counterfeit vaccines would be sold. In the United States, some well-connected companies, like Bloomberg, have secured doses for employees.

...

"Pakistan says the private program could make more free shots available to low-income people. By purchasing doses of the Russian-made Sputnik 5 vaccine, the country’s wealthy wouldn’t need to get the free doses, which are made by Sinopharm of China. Some people would prefer to get inoculated at a private hospital because they are widely believed to be comparatively better organized and more efficient than overwhelmed government facilities.

Transplantation across ethnic divisions in Israel

 Transplantation sometimes makes for complicated stories.

Kidney from Jew killed in mob violence goes to Arab woman.  By Hadas Gold and Michael Schwartz, CNN

" Randa Aweis, 58, waited nine years for the organ donation that would change her life.

"An Arab Christian, born in the Old City of Jerusalem, she was relying on regular dialysis sessions as her kidneys failed. Then the call came: A donor kidney was available. Aweis had surgery Monday at Jerusalem's famed Hadassah University Hospital Ein Kerem. When she went under the anaesthetic, she did not know who the donor was.

"Only afterwards did she find out that it was Yigal Yehoshua, a Jewish Israeli man who died in the wave of violence between Jews and Arabs in the Israeli town of Lod.

...

"Yehoshua, 56, was critically injured on May 11 after being attacked by a group of young Arab Israeli men in Lod.

...

"Her surgeon, Dr. Abed Khalaeileh -- a Palestinian born in Jerusalem -- said he and his colleagues simply treat everyone as human beings.

HT: Itai Ashlagi