Global kidney exchange: followup report on the first GKE chain

Here's a report, 3 years after, of the first global kidney exchange chain. Among the authors are the Filipino physicians who are providing ongoing care for the Filipino donor and recipient:

Complete Chain of the First Global Kidney Exchange Transplant and 3-yr Follow-up

Author links open overlay panelDanielle N.BozekabTy B.DunncChristian S.KuhrdChristopher L.MarsheJeffreyRogersfSusan E.ReesbLauraBasagoitiagRobert J.BrunneraAlvin E.RothhObiEkwennaabDavid E.FumoabKimberly D.KrawieciJonathan E.KopkebPuneetSindhwaniaJorgeOrtizaMiguelTanjSiegfredo R.PaloyoklJeffrey D.PunchmMichael A.Reesab

https://doi.org/10.1016/j.euf.2018.07.021Get rights and content

European Urology Focus

Available online 23 August 2018

In Press, Corrected ProofWhat are Corrected Proof articles?

Abstract

Background

Global Kidney Exchange (GKE) offers an opportunity to expand living renal transplantation internationally to patients without financial means. These international pairs are entered into a US kidney exchange program that provides long-term financial support in an effort to identify opportunities for suitable exchanges for both these international pairs and US citizens.

Objective

While the promise of GKE is significant, it has been met with ethical criticism since its inception in 2015. This paper aims to demonstrate the selection process and provide >3 yr of follow-up on the first GKE donor and recipient from the Philippines.

Design, setting, and participants

The first GKE transplant occurred with a young Filipino husband and wife who were immunologically compatible, but lacked the financial means to continue hemodialysis or undergo a kidney transplant in their home country. The pair was enrolled in the Alliance for Paired Donation matching system, several alternative kidney exchanges were identified, and the pair subsequently underwent renal transplantation and donation in the USA financed by philanthropy. The resulting nonsimultaneous extended altruistic chain provided transplantation for the Filipino husband and 11 US patients.

Outcome measurements and statistical analysis

The Filipino donor and recipient were followed by transplant professionals in both the Philippines and the USA. Follow-up data were maintained as required by the Organ Procurement and Transplantation Network in the USA.

Results and limitations

The Filipino donor has normal blood pressure and renal function, and the Filipino recipient is doing well 3.5 yr after their donation and transplantation.

Conclusions

While criticisms of GKE highlight concerns for possible exploitation of financially disadvantaged groups, these results demonstrate that these concerns did not come to fruition, and the outcome experienced by the GKE donor and recipient (and other US participants) was successful.

Patient summary

The first Filipino Global Kidney Exchange (GKE) donor-recipient pair continues to be followed by both US and Filipino transplant centers. Both are in good health, support the GKE program, and advocate for its expansion.

Blockchain and legal but repugnant markets--a guest post by Stephanie Hurder

Below is a guest post, by Stephanie Hurder — a Harvard Economics Ph.D. (who I've blogged about before, here, and here) and a founder of blockchain economics startup Prysm Group (that I’ve blogged about here). She discusses how blockchain may impact repugnant markets.

As Al has written about for years, repugnance -- the distaste for certain kinds of transactions -- can be a serious constraint on markets.   Repugnance can stem from numerous sources, such as a fear of coercion or of a slippery slope.  And while the constraints created by repugnance sometimes end up incorporated in to law, they do not need to be legal to have significant impact.  Businesses may voluntarily choose not to provide services that some set of consumers might find repugnant, in order to maintain their brand reputation and prevent a loss of those customers.

Firms that engage in legal, adult activities -- such as pornography and the sale of sex toys -- have significant issues accessing financial services due to the constraints imposed by repugnance.  Most commercial banks include “morality clauses” forbidding service of businesses engaging in adult activities, for reputational reasons.   Newer payment services that would like to serve “repugnant” industries are constrained by these more conservative organizations, with whom they must do business in order to effectively process payments and offer services.

Stripe, the payments processor, has publicly discussed this phenomenon on their blog.  Stripe was approached by OMGYes, a website that provides actionable, research-backed information on sex.  They write:

The business approached us and we were eager to work with them, but after a month of deliberations, our financial partners did not agree. Instead, because the website has explicit tutorials, it still falls under the umbrella of unsupportable businesses. While we were not able to persuade our financial partners this time around, we will continue to holistically look at and advocate for businesses that sell adult products and services.

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By now, almost all industries are exploring how to leverage the economic benefits of blockchain, especially those arising from blockchain’s ease of verification and decentralization.  One type of use case with significant potential is using blockchain to provide services to markets constrained by repugnance. 

Cryptocurrencies such as Bitcoin are a potential payments solution for industries not served by traditional financial service providers.  However, a payment system by itself is not enough -- the anonymity of some cryptocurrencies can increase the probability that genuinely coercive or even illegal activities will take place.  Effective platforms serving repugnance markets will need to combine the decentralized benefits of blockchain and cryptocurrencies with more traditional levers of market design, such as reputation.

An example of a company doing exactly this is intimate.io.  intimate.io is an Ethereum-based platform for individuals engaged in the adult industry.  It provides secure, decentralized transfer of payments for adult services.  It also includes pseudonymous reputation and user information (such as age verification and relevant health information) to help service providers vet customers and vice versa.  Two-party escrow provides financial incentives for users to behave cooperatively.  

intimate.io CEO, Leah Callon-Butler, writes:

Blockchain is a technology crying out for a use-case and intimate.io brings together several different blockchain-based technologies, to demonstrate unprecedented real-world utility through application to an industry that is sorely in need of emancipation from centralised bodies who have assumed the role of moral arbiter for too long.

While platforms like intimate.io open the possibility for market participants to work around roadblocks imposed by repugnance, they face many of  the same market design and data management challenges as other industries.  How will sensitive information (such as health data) be verified and provided to the market, while preserving privacy?  How will the platform ensure that users banned for poor behavior do not create new identities?  Innovative solutions to these issues can inform market design more broadly.

It will also be interesting to see how the “traditional” financial system reacts to blockchain platforms like intimate.io.  Luke Coffman at Harvard has shown that introducing an intermediary in a business transaction can lessen the punishments for “immoral” behavior that consumers give to companies.  How many steps of separation -- and of what kind -- will be required between traditional banks and platforms like intimate.io so that markets constrained by repugnance can finally be served?

Five approaches to the opioid crisis, by pharmacologists, doctors, insurers, prosecutors, and legislators

Five very different approaches to the opioid crisis--by
1. pharmacologists/biologists, 2. physicians, 3. payers,  4. prosecutors, and 5.legislators:

1. From PNAS:
Safer opioids may be on the horizon, but mitigating addiction is a long shot, by Jyoti Madhusoodanan

2. From Science:
Opioid prescribing decreases after learning of a patient’s fatal overdose, by
Jason N. Doctor, Andy Nguyen, Roneet Lev, Jonathan Lucas, Tara Knight, Henu Zhao, Michael Menchine

3. From the Chicago Trib, and from Stat:
Chicago limits opioid prescriptions for city employees

Tapered to zero: In radical move, Oregon’s Medicaid program weighs cutting off chronic pain patients from opioids

4. From Reuters:
New York sues OxyContin maker Purdue Pharma over opioids

5. From the NY Times
Congress Is Writing Lots of Opioid Bills. But Which Ones Will Actually Help?


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And here's an article from the NY Times on the magnitude of the crisis:

Bleak New Estimates in Drug Epidemic: A Record 72,000 Overdose Deaths in 2017: Fentanyl is a big culprit, but there are also encouraging signs from states that have prioritized public health campaigns and addiction treatment.

"Strong synthetic opioids like fentanyl and its analogues have become mixed into black-market supplies of heroin, cocaine, methamphetamine and the class of anti-anxiety medicines known as benzodiazepines."

Signaling and matching in an online labor market, by Horton and Johari

Here's a paper on signaling and matching in a prominent but un-named online labor market that is readily identifiable.

Engineering a Separating Equilibrium

John J. Horton and Ramesh Johari
August 14, 2018

Abstract: This  paper  explores  whether  platform-created  signaling opportunities can move designed markets to more desirable equilibria.  In a large on-line  labor  market,  buyers  were  given  the  opportunity  to  signal  their relative  preferences  over  price  and  quality.   The  intervention  caused substantial sorting by sellers to buyers of the right “type.”  However, sellers clearly tailored their bids to the type of buyer they faced, bidding up against sellers with a high revealed willingness to pay.  Despite this “markup,” a separating equilibrium was sustained over time, suggesting buyers found revelation incentive compatible.  We find evidence that informative signaling improved matching efficiency and match quality.

"The signaling opportunity was simple:  when posting a job opening,  employers selected one of three “tiers” to describe the kinds of applicants they were most interested in:  (1) Entry level:  “I am looking for [workers] with the lowest rates.”;  (2) Intermediate:  “I am looking for a mix of experience and value.”; (3) Expert:  “I am willing to pay higher rates for the most experienced [workers].”  We refer to these tiers as “low,” “medium,” and “high,” respectively.   When  the  signaling  opportunity  was  introduced  market-wide  (which occurred after an experimental period), the tier choice was revealed publicly to all job-seeking workers."
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No comment(s)

In July, just before travelling, I closed the comments on this blog, not because I don't appreciate smart topical comments, but because every morning I had to delete spammy comments on old posts by people purporting to buy kidneys.

Here are those from the last day I allowed comments

	We are urgently in need of kidney donors in wockhardt hospital India for the sum of $500,000,00,( 3 CRORE INDIA RUPEES) All donors are to reply via Email: wockhardthospital7@gmail.com on The Econometrics of Matching Models by Pierre-André Chiappori and Bernard Salanié in the JEL	wockhardt hospital	on 7/12/18
	We are urgently in need of kidney donors in wockhardt hospital India for the sum of $500,000,00,( 3 CRORE INDIA RUPEES) All donors are to reply via Email: wockhardthospital7@gmail.com on Organ donation rates in Canada	wockhardt hospital	on 7/12/18
	We are urgently in need of kidney donors in wockhardt hospital India for the sum of $500,000,00,( 3 CRORE INDIA RUPEES) All donors are to reply via Email: wockhardthospital7@gmail.com on Raj Chetty at the LSE: How Can We Improve Economic Opportunities for Low-Income Children?	wockhardt hospital	on 7/12/18
	We are urgently in need of kidney donors in wockhardt hospital India for the sum of $500,000,00,( 3 CRORE INDIA RUPEES) All donors are to reply via Email: wockhardthospital7@gmail.com on More on kidney black markets in India	wockhardt hospital	on 7/12/18
	We are urgently in need of kidney donors in global hospitals group India for the sum of $500,000,00,( 3 CRORE INDIA RUPEES) All donors are to reply via Email: onlinecareunit@gmail.com on 77 Kidney Exchange transplants in 2015 at one transplant center in India	Global Hospitals Group	on 7/12/18
	We are urgently in need of kidney donors in global hospitals group India for the sum of $500,000,00,( 3 CRORE INDIA RUPEES) All donors are to reply via Email: onlinecareunit@gmail.com on Ten kidney exchange transplants on World Kidney Day in Ahmedabad, India Delete | Not spam	Global Hospitals Group	on 7/12/18

Pay transparency, by Cullen and Pakzad-Hurson

Here's a contribution to the sometimes confusing debate about salary transparency.

''Equilibrium Effects of Pay Transparency in a Simple Labor Market"

Zoe B. Cullen and Bobak Pakzad-Hurson

Abstract: Public discourse on pay transparency has not focused on equilibrium effects:  how greater transparency  impacts  hiring  and  bargaining.   To  study  these  effects,  we  combine  a  dynamic  wage-bargaining model with unique data of temporary work arrangements that differ in their level of transparency.  Full transparency lowers wages by up to 25% and increases hiring by similar magnitudes.  Earnings inequality falls, and employer profits rise significantly.  A key intuition is high transparency commits employers to negotiating aggressively, because a highly paid worker’s salary affects  negotiations  with  other  workers.   We  discuss  implications  for  the  gender  wage  gap  and employers’ endogenous transparency choices.

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Here are some earlier posts that touch on related issues:

Wednesday, August 17, 2016

Salary negotiation: some Massachusetts market design

The NY Times has the story: Massachusetts Bans Employers From Asking Applicants About Previous Pay

Sunday, May 5, 2013

Market culture and salary discussions

Martin Shubik, 1926-2018

Ed Kaplan emails me with the sad news that Martin Shubik died yesterday.

Here's the first brief announcement from Yale School of Management:
Prof. Martin Shubik, Influential Game Theory Scholar, Dies

He was a pioneering game theorist, and a frequent collaborator with his graduate school roommate Lloyd Shapley. My understanding is that the two of them shared a double room, in a suite with John Nash. 

He suffered from a rare disease, Inclusion Body Myositis, and established a charity to organize research about it, Inclusion Body Myositis Registry at Yale.

He was a man of many parts. (See here, for example.)

Here are two photos I took of him at a Stonybrook conference in honor of Shapley. (In the second he must have been proving an especially difficult theorem...)

Martin Shubik in 2003

Two papers by Shapley and Shubik played important roles in areas in which I've worked:

The second (by publication date) was their landmark 1971 paper on matching as an assignment game (with all payments freely transferable), published in volume 1 number 1 of the International Journal of Game Theory: The assignment game I: The core

(Years after it was published, I asked Shapley what ever happened to part II, and his reply was "Never call a paper part I unless you have already written part II."  As I recall, he further said that the plan for the never-written part II had been to study the von Neumann-Morgenstern solutions of the assignment game.)

The first was their famous 1954 paper in the American Political Science Review, perhaps Shubik's most cited, on how to evaluate the strength of each position in "simple" coalitional games, in which every coalition is either 'winning' or 'losing'
A Method for Evaluating the Distribution of Power in a Committee System

I have many times used his model of escalation, The Dollar Auction Game, as an in-class demonstration of the importance of auction rules for auction outcomes and strategies.

Historians of game theory are sure to learn a lot from the archives of his papers and correspondence at Duke:
The Martin Shubik Papers: From Early Game Theory to the Strategic Analysis of War
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Update: Yale SOM has now published a long, fond remembrance:
Remembering Prof. Martin Shubik, 1926–2018

Take a break: avoiding congestion in ant colonies and elsewhere

A recent paper in Science is introduced by the NY Times under this headline:

The Secret to Ant Efficiency Is Idleness

Here's the paper:
Collective clog control: Optimizing traffic flow in confined biological and robophysical excavation
J. Aguilar, D. Monaenkova, V. Linevich, W. Savoie, B. Dutta, H.-S. Kuan,  M. D. Betterton, M. A. D. Goodisman, D. I. Goldman

Here's the abstract of the paper (preceded by another description, perhaps written by a writer for Science(?) meant to be more intelligible...

When fewer workers are more efficient:
"A narrow passageway can easily become clogged or jammed if too much traffic tries to enter at once or there is competition between the flow of traffic in each direction. Aguilar et al. studied the collective excavation observed when ants build their nests. Because of the unequal workload distribution, the optimal excavation rate is achieved when a part of the ant collective is inactive. Numerical simulations and the behavior of robotic ants mimic the behavior of the colony."

Abstract: Groups of interacting active particles, insects, or humans can form clusters that hinder the goals of the collective; therefore, development of robust strategies for control of such clogs is essential, particularly in confined environments. Our biological and robophysical excavation experiments, supported by computational and theoretical models, reveal that digging performance can be robustly optimized within the constraints of narrow tunnels by individual idleness and retreating. Tools from the study of dense particulate ensembles elucidate how idleness reduces the frequency of flow-stopping clogs and how selective retreating reduces cluster dissolution time for the rare clusters that still occur. Our results point to strategies by which dense active matter and swarms can become task capable without sophisticated sensing, planning, and global control of the collective.

Modern congestion pricing, by Cramton, Geddes and Ockenfels

Here's a short paper in the July 31 Nature:
Set road charges in real time to ease traffic
Track vehicles to link tolls with demand and cut congestion, urge Peter Cramton, R. Richard Geddes and Axel Ockenfels

And here's the longer working paper:
Markets for Road Use: Eliminating Congestion through Scheduling, Routing, and Real-Time Road Pricing
Peter Cramton, R. Richard Geddes, and Axel Ockenfels

Their vision:

"Efficient pricing of network capacity is not new. Indeed, wholesale electricity markets have been dynamically priced for over a decade. Communications markets are adopting dynamic pricing today. Efficient pricing of road use, however, has only recently become feasible. Advances in mobile communications make it possible to identify and communicate the location of a vehicle to within one cubic meter—allowing precise measurement of road use. User preferences can be communicated both in advance to determine scheduled transport and in real time to optimize routes based on the latest information. Computer advances also facilitate efficient scheduling and pricing of road use. Consumer apps help road users translate detailed price information into preferred transport plans. Computers also allow an independent system operator to better model demand and adjust prices to eliminate congestion and maximize the total value of road infrastructure. An independent market monitor, distinct from the
operator, observes the market, identifies problems, and suggests solutions. A board governs the market subject to regulatory oversight."

An egregious repugnant transaction

When I speak about repugnant transactions--transactions which some people voluntarily engage in, but other people think they shouldn't, or perhaps shouldn't even be allowed to--I sometimes run into some skepticism from economists who point out that voluntary transactions generally increase welfare, and that to restrict them is paternalistic.

Nevertheless, many people have that (paternalistic) impulse at least sometimes.
Test yourself on this one, from the Guardian:

British stag group in Spain 'paid homeless man to get face tattoo'
Anger in Benidorm as Polish national given £90 to have groom’s name on forehead

"British tourists on a stag party in Benidorm have provoked outrage by paying a homeless man to have the name of the groom tattooed on his forehead, a local business leader has said.

Karen Maling Cowles, the president of the Benidorm British Business Association, said the group gave 34-year-old Tomek, originally from Poland, €100 (£89) to have “Jamie Blake, North Shields, NE28” inked on his head...
...
"Residents of the Spanish resort criticised the stag group after the tattoo parlour posted a photo on Facebook, since taken down, of Tomek getting the tattoo."
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HT: Muriel Niederle

Medically assisted death debated in Australia

A bill is under consideration in Australia regarding medically assisted suicide, aka death with dignity.  (The politics are complicated by the fact that Australia has both states and territories.) Here's the story from the Guardian:

David Leyonhjelm confident voluntary euthanasia bill will pass Senate
Liberal Democrat pressures Malcolm Turnbull to permit vote in lower house

"The bill to allow the Northern Territory and Australian Capital Territory to legislate for euthanasia – reversing a ban imposed by the commonwealth in 1997 – has support from at least 18 Labor senators, the nine Greens, eight crossbench senators and a small but growing group of Coalition senators. It needs 39 to pass the Senate.
...
"“Australians with a terminal illness should have a right to die with dignity, ideally with effective palliative care, but with sufficient safeguards, that right, in extreme cases, should also extend to voluntary euthanasia.”
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An earlier, related post:

Friday, May 4, 2018

Death with dignity: David Goodall flies from Australia to Switzerland

Data mining for knowledge discovery in London

24rd SIGKDD Conference on Knowledge Discovery and Data Mining
August 19 - 23, 2018 - London, UK

Here's the program.  I'll be speaking on Wednesday morning, on Market Design and Computerized Marketplaces:

Keynote speakers

David Hand

SENIOR RESEARCH INVESTIGATOR
EMERITUS PROFESSOR OF MATHEMATICS, IMPERIAL COLLEGE

Alvin E. Roth

NOBEL MEMORIAL PRIZE IN ECONOMICS
PROFESSOR OF ECONOMICS, STANFORD UNIVERSITY

Yee Whye Teh

PROFESSOR,DEPARTMENT OF STATISTICS, UNIVERSITY OF OXFORD
RESEARCH SCIENTIST, DEEPMIND

Jeannette M. Wing

AVANESSIANS DIRECTOR OF THE DATA SCIENCES INSTITUTE 
COLUMBIA UNIVERSITY

Diversity isn't just about role models: Alsan, Garrick and Graziani on black male doctors and patients

Medical compliance--following the doctor's "orders,"--is a big issue in medical care, and here's an article that reports a novel field experiment suggesting that black male doctors treating black men may have more success than non-black docs.

Does Diversity Matter for Health? Experimental Evidence from Oakland
Marcella Alsan, Owen Garrick, Grant C. Graziani
NBER Working Paper No. 24787

"We study the effect of diversity in the physician workforce on the demand for preventive care among African-American men. Black men have the lowest life expectancy of any major demographic group in the U.S., and much of the disadvantage is due to chronic diseases which are amenable to primary and secondary prevention. In a field experiment in Oakland, California, we randomize black men to black or non-black male medical doctors and to incentives for one of the five offered preventives — the flu vaccine. We use a two-stage design, measuring decisions about cardiovascular screening and the flu vaccine before (ex ante) and after (ex post) meeting their assigned doctor. Black men select a similar number of preventives in the ex-ante stage, but are much more likely to select every preventive service, particularly invasive services, once meeting with a doctor who is the same race. The effects are most pronounced for men who mistrust the medical system and for those who experienced greater hassle costs associated with their visit. Subjects are more likely to talk with a black doctor about their health problems and black doctors are more likely to write additional notes about the subjects. The results are most consistent with better patient-doctor communication during the encounter rather than differential quality of doctors or discrimination. Our findings suggest black doctors could help reduce cardiovascular mortality by 16 deaths per 100,000 per year — leading to a 19% reduction in the black-white male gap in cardiovascular mortality.
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While there's no substitute for the kind of serious science reported in the paper above, below is a very believable anecdotal account in an interview published in Stat that suggests that companies seeking to solve medical problems afflicting women may have more success with venture capital firms that have women partners:

A women’s health startup tried to drum up interest for a much-needed drug. Many men didn’t get it

Kidney exchange on NPR

Two friends told me that they'd heard me on NPR yesterday, and so I searched and found this program on kidney exchange. (At the link below you can read the transcript, and also see a 9 minute video that apparently played on tv.) They interview patients, donors, and kidney docs, and feature two economists, me and Nikhil Agarwal.  (My part seems to be pieced together from footage from a talk I gave at a Google conference, and a video made by the National Academy of Sciences, but it looks like they actually interviewed Nikhil...)

The economic principle that powers this kidney donor market
Aug 16, 2018 6:20 PM EDT

I can't figure out how to embed the video in this post, but here's a picture that's just a screen shot, not a link:

An open marketplace for reinsurance

Tremor Technologies Inc. has announced its new online marketplace for reinsurance.  Here's the press release:

Tremor Technologies, Inc., a venture-backed startup based in Greenwich, CT, has announced that its programmatic risk placement marketplace is fully operational with significant buyers and sellers of reinsurance protection in place.


And here's an article with a little more detail:

Tremor opens programmatic marketplace for reinsurance risk placement
by ARTEMIS on AUGUST 14, 2018

"The company has venture capital backing and has been developing its technology platform and building a team of marketplace design experts* for two years now, with the resulting smart market now available.
...
"Peter Cramton, Tremor’s Chief Economist and a recognised international expert on auction theory and practice, as well as market design, commented, “We maximize value for both sides of the market and then fairly share that value among participants with competitive clearing prices.”

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*full disclosure--I'm on Tremor's advisory board.

Why aren't clearinghouses used in college admissions?

I recently had an email from  Professor Deepak Hegde, at NYU's Stern School who asked me a question that led to the following exchange (edited for brevity and reproduced with his permission):

"Why are admission decisions in a broader set of settings (e.g., Phd applicants-programs, MBA applicants-to-business schools and so on)  not cleared through matching programs as is done with medical schools and residency applicants (or in some cases public schools matching)?   Are there a general set of conditions that one could develop to understand the contexts in which the matching algorithm that have helped advance could be implemented effectively?"

I replied as follows:

"I certainly don’t have a complete answer, but one obvious piece is that setting up a centralized clearinghouse for a whole market involves getting a lot of parties to coordinate and cooperate.  So I would guess that MBA admissions have a better chance of getting organized than, say Ph.D. admissions, since MBA programs are more alike one another than are Ph.D. programs (e.g. in Physics and Philosophy, or Chemistry and Chinese).

"And since wide scale cooperation is hard, I think it mostly happens in market in which people are very dis-satisfied with the existing system, and not just somewhat irritated.

"Is it your sense that MBA admissions is in a crisis of some sort?"

His reply: "In my assessment ... MBA admissions is not facing such a crisis, yet."

So...I think the MBA Match isn't something we'll hear about in the near future.