New rules for evaluating transplant centers

 Historically, transplant centers ('hospitals') have been primarily evaluated on the one year graft survival on the transplants that they do.*  Now Medicare announces it will test a new model, that will emphasize the number of transplants conducted ("achievement"), in addition to somewhat less emphasis on the ratio of deceased donor kidneys accepted or rejected ("efficiency") and graft survival ("quality").

Medicare Program; Alternative Payment Model Updates and the Increasing Organ Transplant Access (IOTA) Model.  A Rule by the Centers for Medicare & Medicaid Services on 12/04/2024 

"a. Proposed IOTA Model Overview

"End-Stage Renal Disease (ESRD) is a medical condition in which a person's kidneys cease functioning on a permanent basis, leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life.[2]

"The best treatment for most patients with kidney failure is kidney transplantation. Nearly 808,000 people in the United States are living with ESRD, with about 69 percent on dialysis and 31 percent with a kidney transplant.[3]

"Relative to dialysis, a kidney transplant can improve survival, reduce avoidable health care utilization and hospital acquired conditions, improve quality of life, and lower Medicare expenditures.[4 5]

"However, despite these benefits of kidney transplantation, evidence shows low rates of ESRD patients placed on kidney transplant hospitals' waitlists, a decline in living donors over the past 20 years, and underutilization of available donor kidneys, coupled with increasing rates of donor kidney discards, and wide variation in kidney offer acceptance rates and donor kidney discards by region and across kidney transplant hospitals.[6 7] 

...

"The IOTA Model will be a mandatory model that will begin on July 1, 2025, and end on June 30, 2031, resulting in a 6-year model performance period comprised of 6 individual performance years (“PYs”). The IOTA Model will test whether performance-based incentives paid to, or owed by, participating kidney transplant hospitals can increase access to kidney transplants for patients with ESRD, while preserving or enhancing quality of care and reducing Medicare expenditures. CMS will select kidney transplant hospitals to participate in the IOTA Model through the methodology proposed in section III.C.3.d of this final rule. As this will be a mandatory model, the selected kidney transplant hospitals will be required to participate. CMS will measure and assess the participating kidney transplant hospitals' performance during each PY across three performance domains: achievement, efficiency, and quality.

"The achievement domain will assess each participating kidney transplant hospital on the overall number of kidney transplants performed during a PY, relative to a participant-specific target. The efficiency domain will assess the kidney organ offer acceptance rate ratios of each participating kidney transplant hospital relative to a national ranking or the participating kidney transplant hospital's past organ offer acceptance rate ratio. The quality domain will assess the quality of care provided by the participating kidney transplant hospitals via a composite graft survival ratio. Each participating kidney transplant hospital's performance score across these three domains will determine its final performance score and corresponding amount for the upside risk payment that CMS would pay to the participating kidney transplant hospital, or the downside risk payment that would be owed by the participating kidney transplant hospital to CMS. The upside risk payment will be a lump sum payment paid by CMS after the end of a PY to a participating kidney transplant hospital with a final performance score of 60 or greater. Conversely, beginning in PY 2, the downside risk payment will be a lump sum payment paid to CMS by any participating kidney transplant hospital with a final performance score of 40 or lower. There is no downside risk payment for PY 1 of the model.

...

"The three performance domains will include: (1) an achievement domain worth up to 60 points, (2) an efficiency domain worth up to 20 points, and (3) a quality domain worth up to 20 points.

"The achievement domain will assess the number of kidney transplants performed by each IOTA participant for attributed patients, with performance on this domain worth up to 60 points. The final performance score will be heavily weighted on the achievement domain to align with the IOTA Model's goal to increase access to kidney transplants to improve the quality of care and reduce Medicare expenditures. The IOTA Model theorizes that improvement activities, including those aimed at reducing unnecessary deceased donor discards and increasing living donors, may help increase access to kidney transplants."

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CMS gives a high level overview here: Increasing Organ Transplant Access (IOTA) Model

and later today there's a webinar you can register for:

"The CMS Innovation Center will be hosting a welcome webinar to present an overview of the model on December 18, 2024, from 2 to 3 p.m. ET. Register to attend: https://cms.zoomgov.com/webinar/register/WN_hvGDyZTxQ5eNhX1OBolevA
 

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*see Wednesday, October 2, 2024 Regulation of Organ Transplantation and Procurement (Chan and Roth in the JPE)

That paper suggests desirable regulations  would coordinate transplant and OPO incentives, and link them both to the health outcomes of all patients attributable to a given transplant center (and not just those patients who were transplanted). 

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quick update (from the Q&A following the webinar): 

this is viewed as an experiment on roughly half the transplant centers, but there isn't currently a commitment about what to do after the projected 6 years of the experiment.

. all transplant patients are considered, but payments are only for Medicare fee for service patients

achievement: . each center's target for annual transplants will be it's average number over the three years ending a year before the beginning of the experiment...(at least that was the answer for the first year).

    . both deceased and living donor outcomes will be included in the achievement metric.

quality: .the first year will consider one-year graft survival, and year n will consider graft survival for the first n years.

OPOs: there are no requirements for OPOs within the IOTA model 

risk adjustment: not for year 1, they are hoping to have risk adjustment measures in subsequent years.

. 

Regulation of Organ Transplantation and Procurement (Chan and Roth in the JPE)

 Here's a new paper (in final form, online ahead of print) on how organ transplants are regulated.  The paper uses an experiment to make several points about the design of current regulations.  One of them is that transplant centers are incentivized to be risk averse, since they are measured only by the outcomes of the transplants they perform, and not on the outcomes for patients they decline to transplant (so they are reluctant to transplant risky kidneys or risky patients).

Regulation of Organ Transplantation and Procurement: A Market-Design Lab Experiment by Alex Chan and Alvin E. Roth, Journal of Political Economy, online ahead-of-print .

 Abstract: We conduct a lab experiment that shows that current rules regulating transplant centers (TCs) and organ-procurement organizations (OPOs) create perverse incentives that inefficiently reduce both organ recovery and beneficial transplantations. We model the decision environment with a two-player multiround game between an OPO and a TC. In the condition that simulates current rules, OPOs recover only the highest-quality kidneys and forgo valuable recovery opportunities, and TCs decline some beneficial transplants. Alternative regulations that reward TCs and OPOs together for health outcomes in their entire patient pool lead to behaviors that increase organ recovery and appropriate transplants.

Here's what transplants look like in our experimental environment:

And our results are robust to big changes in parameters:

Allocating and reallocating scarce medical supplies

An op-ed in USA today points out that shortages of critical hospital supplies are occurring and will continue to occur at different times in different states, allowing for increased efficiencies in sharing (which is hampered by a vacuum in leadership at the Federal level).

One of the authors, Dr. Deborah Proctor, is in fact an experienced market designer, who led the (re-)adoption of a fellowship match for gastroenterology fellows.*

National redistribution of hospital supplies could save lives
Taking supplies from less stressed hospitals and sharing them with overwhelmed ones, we could maximize the use of equipment and save more lives.
Diane R. M. Somlo, Dr. Howard P. Forman and Dr. Deborah D. Proctor

"Since we now know more about the predicted peaks in COVID-19 across the U.S., we can see that peak demand will likely occur at different times in different states and cities, starting in early April and extending through May. While some hospitals are already starting to drown, other hospitals that are further from their peak demand have stockpiles of unused equipment lying in wait. 

"What if there was a nation-wide system that allowed hospitals that have equipment but have lower present and predicted demand to lend some reusable (ventilator) and non-reusable equipment (PPE, testing kits) to hospitals that are currently being overwhelmed? Then, as demand in one area rises and the other falls, freed up ventilators could be re-distributed, and manufacturers will have had more time to generate non-reusable equipment for hospitals that lent their equipment. By taking from stockpiles of less stressed hospitals and sharing it with currently overwhelmed ones, we could maximize the use of our national inventory of equipment and save more lives.
...
" redistribution approaches in other settings have enabled vast functional expansions of limited supplies, including kidney transplants and donated food for food pantries across the U.S. Bottom line: Redistribution has the potential to improve the trajectory of COVID-19 mortality in the U.S. Our country is already on track to employ these measures at a state level or voluntarily, so delaying set up of cross-state exchange only means missing out on the maximal benefit of redistribution. In fact, as of this writing, New York’s Governor Andrew Cuomo has just signed an executive order enabling redistribution of medical supplies to struggling hospitals within New York state and Oregon has sent ventilators to New York.

"In these coming trying times, our healthcare system is facing an unprecedented, deadly burden, and we need to make supplies available where they are needed most —independent of state lines. Now is the time to start making the changes, to call on the federal government, national leaders, and private partnerships to coordinate our efforts as a nation, so we can provide the best care possible with our limited supplies. Lives depend on it."

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* Niederle, Muriel, Deborah D. Proctor and Alvin E. Roth, ''The Gastroenterology Fellowship Match: The First Two Years,'' Gastroenterology , 135, 2 (August), 344-346, 2008.

Matching patients to health care in China

When I travel in China, one topic that often comes up is that there should be a better way of matching patients to doctors in Chinese hospitals.  Here's a story in the NY Times about that:

China’s Health Care Crisis: Lines Before Dawn, Violence and ‘No Trust’ 
By Sui-Lee Wee

"Well before dawn, nearly a hundred people stood in line outside one of the capital’s top hospitals.

"They were hoping to get an appointment with a specialist, a chance for access to the best health care in the country. Scalpers hawked medical visits for a fee, ignoring repeated crackdowns by the government.
...
"The long lines, a standard feature of hospital visits in China, are a symptom of a health care system in crisis.
...
"China has one general practitioner for every 6,666 people, compared with the international standard of one for every 1,500 to 2,000 people, according to the World Health Organization.

Instead of going to a doctor’s office or a community clinic, people rush to the hospitals to see specialists, even for fevers and headaches. "

An electronic board at the entrance of Peking Union Hospital displays the number of doctors available and their specialty.CreditGilles Sabrié for The New York Times

Regulation of the hours that medical residents can work

The Chronicle of Higher Education reports Accreditor Tightens Limits on Medical Residents' 80-Hour Workweeks

"Doctors in training at teaching hospitals would continue to be limited to an 80-hour workweek, but some new limits would be imposed to cut down on errors by sleep-deprived residents under new standards approved on Tuesday by the Accreditation Council for Graduate Medical Education.


"The standards, which are scheduled to take effect in July 2011, will apply to the 111,000 medical residents who are training in accredited teaching institutions,

"Residents can work more than 80 hours some weeks, as long as the average over a four-week period doesn't exceed 80. First-year residents would be limited to working no more than 16 hours a day—down from 24 hours—and they would be supervised more closely. Residency-training programs would also have a tougher time getting exceptions to the work-hour limits.

"The changes are based on recommendations made in 2008 by the Institute of Medicine, which warned of widespread medical errors caused by sleepy residents, as well as a 16-month review of scientific writings on sleep issues, patient safety, and resident training.

"Some teaching hospitals have argued that limiting residents' work hours would hurt them financially without necessarily improving patient safety.

"The revised standards, which also deal with concerns about mistakes that occur when residents hand off patient-care responsibilities during shift changes, were developed by a 16-member task force made up of specialists from medical education, patient safety, and clinical care."

Work hours of surgical residents

The culture is changing to comply with the law, but it's hard.

For doctors, a matter of time: MGH residents cut back to 80-hour weeks, but with mixed feelings

"The hospital had a wake-up call last year, when a national accrediting agency put the program on probation for violating patient-protection rules that limit trainees’ work hours. Some junior surgeons, called residents, had been staying too late because they didn’t want to sign over their very sick patients to other doctors, out of a combination of duty to patients, work ethic, and unspoken peer pressure.

"Now, say senior surgeons and residents alike, the program is in complete compliance with the rules that require trainees to average no more than 80 hours of work a week and have 10 hours off between shifts."


The story makes the case that residents sometimes need and want to work long hours.


A related story about sleeplessness makes the case that it would be good both for patients and young docs if they got enough sleep: At Midnight, All the Doctors…

Market for doctors: work rules for surgical residents

Surgical residents are young doctors in training, and there is an ongoing conflict playing out between perceptions of their training needs and patient well being and safety. The Boston Globe reports: MGH cited on surgeons' overload, Trainees' hours exceed safety rule; Hospital says it has fixed problem.

"Junior surgeons at Massachusetts General Hospital have been working too many hours, in violation of patient safety rules, according to a national accrediting organization that is threatening to put the hospital’s surgery training program on probation.
The Accreditation Council for Graduate Medical Education cited the hospital because a significant number of its surgeons in training, known as residents, were exceeding hour limits and working seven days straight. The organization believes these workloads contribute to fatigue-related mistakes, and has given the hospital until Aug. 15 to fix the problem."
...
" But five years after the hour restrictions were adopted, Warshaw and other surgeons said frustration is building at the nation’s teaching hospitals, because residents believe the rules interfere with their work and ultimately may harm, rather than help, patients.
The council acknowledged the tension in its April 13 letter to Mass. General, in which reviewers wrote: “The greatest challenge . . . has been getting the culture of the residents to change.’’

..." Dr. Thomas Nasca, head of the accreditation council, lamented in a letter to training programs earlier this year that residents are placed in an “ethical quandary’’ because “we compel them to lie [about their hours] if they do the right thing for their patients.’’
Still, the council is stepping up enforcement, and 5 percent to 10 percent of surgery programs were cited last year, including many of the country’s most prestigious training programs. Beth Israel Deaconess Medical Center was threatened with probation last year, but has since reined in residents’ workloads."
...
"Surgeons are adamantly opposed to tougher limits, saying there is little evidence that sending residents home after a prescribed work shift has improved patient care and that the rules actually may be hurting residents’ education. General surgery residents need to complete at least 750 cases during their five-year training so they are ready to operate on their own once they finish.
Any change would also have financial implications for teaching hospitals, where the nation’s 107,000 residents provide the majority of care."

I haven't done any work related to residents' work rules, but I've done a lot of work related to how residents get hired....

Market for nurses: residencies?

Despite the medical-training ethos of "see one, do one, teach one," newly graduated MD's aren't considered to be independent doctors until they have completed several years of organized on the job training (in the form of residencies and fellowships). Nurses, however, are often thrust directly into relatively unsupervised patient care directly upon graduation.

That may be changing, partly because the stress of being given too much responsibility too soon causes young nurses to leave: Amid Nurse Shortage, Hospitals Focus on Retention.

"Many novice nurses like O'Bryan are thrown into hospitals with little direct supervision, quickly forced to juggle multiple patients and make critical decisions for the first time in their careers. About 1 in 5 newly licensed nurses quits within a year, according to one national study.
That turnover rate is a major contributor to the nation's growing shortage of nurses. But there are expanding efforts to give new nursing grads better support. Many hospitals are trying to create safety nets with residency training programs."
...
"One national program is the Versant RN Residency, which was developed at Childrens Hospital Los Angeles and since 2004 has spread to 70 other hospitals nationwide. One of those, Baptist Health South Florida in the Miami area, reports cutting its turnover rate from 22 percent to 10 percent in the 18 months since it started its program."
...
"The American Association of Colleges of Nursing and the University HealthSystem Consortium teamed up in 2002 to create a residency primarily for hospitals affiliated with universities. Fifty-two sites now participate in that yearlong program and the average turnover rate for new nurses was about 6 percent in 2007."
...
"The National Council of State Boards of Nursing is considering a standardized transition program. It cited a study showing a link between residencies and fewer medical errors, but also pointed to the inconsistency among current efforts."

Market for health care: no law of one price

The Boston Globe ran a story about healthcare costs at different Boston area hospitals, in which fees are negotiated between insurers and individual hospitals: A healthcare system badly out of balance

""The same service delivered the same way with the same outcome can vary in cost from one provider to the next by as much as 300 percent," said Charles Baker, president of the state's second-largest health insurer, Harvard Pilgrim Health Care. "There is no other sector of the economy anywhere in this country in which that kind of price variability with no appreciable difference in service or product quality can sustain itself over time.""

Pricing certainly serves different function in health care than in other parts of the economy, and tertiary care teaching hospitals do more than provide simple patient services (e.g. they also train future docs, about which see my previous post today, on Orthopaedic surgeons). So, as the healthcare system is brought into better balance, some attention will have to be paid to paying for some of the things that now may be paid for with hidden cross-subsidies.


HT Paul Kominers (younger brother of the remarkable if less cool SK)

Market for health care: adding choice in Britain

Choice is having an effect on Britain's National Health Service, the Telegraph reports:
NHS hospital units shunned by patients face closure
NHS hospitals units are facing closure as patients choose to be treated in more successful medical centres, new figures show.

"Patients are now able to choose where they are treated, with many snubbing the traditional visit to their local hospital and opting for units with the best treatment records, facilities and, crucially, cleanliness and infection control.
GPs can also choose where to send their patients. Crucially, hospitals no longer receive a guaranteed block grant and are paid according to the number of patients they treat. "

"The internal market reforms were the source of a bitter struggle within the Labour Government. Tony Blair and Alan Milburn, his Health Secretary, fought against union and backbench opposition to force through many of the changes to the way the NHS was run. "

Labor Market Intermediation

David Autor has an essay on The Economics of Labour Market Intermediation"

"One might have speculated that in an era of rapid information flows and substantial job mobility, the importance of labour market intermediaries would wane. Indeed, the most prominent labour market intermediary, the traditional labour union, has been in secular declines for decades. Yet, the decline of labour unions is the exception rather than the rule. Two of the intermediaries discussed above – online search engines and centralised medical matches – have only recently gained prominence. And another labour market intermediary not even considered above, temporary help agencies, has risen from relative obscurity to international significance over the last two decades. "

Britain's National Health Service and private medicine

Up until now, Britain's NHS has insisted that patients either accept the NHS's formulary which does not cover some expensive drugs, or give up all access to NHS care; i.e. patients who pay for some of their own drugs have been required to pay for all of their drugs and treatment, even those that would have been free to other British citizens. Now, the Telegraph reports:
"NHS patients will be allowed to pay for private 'top up' care: Patients will be allowed to pay privately for drugs and still receive NHS treatment under plans to be announced by the Government in the next fortnight. "

"Under current rules, hospitals may withdraw treatment from patients who want to use their own money to buy drugs not available on the health service.
But Alan Johnson, the Health Secretary, is preparing to announce that so-called top-up payments will be allowed. "
...
"Concerns have been raised that such a move would create a two-tier health service where wealthy patients buy life saving treatments denied to those who cannot afford them.
...The Government ordered a review into top-up payments earlier in the year. There has been a public outcry after some NHS hospitals refused to treat those paying for their own drugs or other treatments."

Market for nurses

The Washington Post runs a story whose sub-headline is Recruitment Plans Focus On Working Conditions Over Financial Rewards . Apparently salary isn't the only way to compete for scarce nurses. Job satisfaction matters too. Who knew?