The organization of organ donation: Jennifer Erikson and Abe Sutton call for an Office of Organ Policy

White House staffers from two very different administrations call for a reorganization of organ donation:

It's time to provide needed reform to the organ donation system
BY JENNIFER ERICKSON AND ABE SUTTON

"Every day, Americans are dying because of an inefficient organ donation system. That reality is as tragic as it is fixable, and cemented a seemingly unlikely friendship between us as two former White House staffers who served two very different presidents.

"It might seem like there are not many points of policy agreement between the Trump and Obama White House, but organ donation reform is one.
...
"Organ donation policy has been split between different agencies within the federal government and even an external federal contractor called the Organ Procurement Transplantation Network. This splintering of responsibilities has led to an unaccountable system with patients left behind. As for one federal contractor responsible for oversight of other contractors, Grassley and Young called out the problem, writing: “we can no longer stand by idly while the fox guards the hen house.”

"The answer is to create a centralized Office of Organ Policy within HHS able to identify opportunities for reform, manage the system, and ensure that lives are saved and taxpayer dollars meant to support the system are not wasted."



HT: Frank McCormick 

Regulation of transplant centers and OPO's

I'll be speaking this morning on regulation of transplantation at the 2020 Winter meetings of the American Society of Transplant Surgeons in Miami.

I'll be in a  Special Invited Presidential Session: Transplantation Metrics Roundtable     Moderators:Lloyd Ratner, MD, MPH Timothy Pruett, MD

Transplantation Metrics Roundtable
Time	End Time	Presentation	Speaker	Moderators
10:05 AM	10:20 AM	Welcome and Introduction	Lloyd Ratner, MD, MPH	Lloyd Ratner, MD, MPH Tim Pruett, MD
10:20 AM	10:35 AM	Introductory Presentation from Dr. Pruett	Tim Pruett, MD
10:35 AM	10:50 AM	Introductory Presentation from Dr. Roth	Al Roth, PhD
10:50 AM	12:00 PM	Transplantation Metrics Roundtable Discussion	All panelists (listed below)

Panel Participants

Paul Conway – Chair of Policy and Global Affairs and Immediate Past President of AAKP

Alexandra Glazier – CEO of New England Donor Services

Rick Hasz, BS, MFS, CPTC – Vice President of Clinical Services for the Gift of Life Donor Program

Maryl Johnson, MD – President of UNOS and Professor of Medicine, Heart Failure & Heart Transplantation at University of Wisconsin

Richard Knight, MBA – President of AAKP

Kevin Longino – CEO of the National Kidney Foundation (NKF)

Jean Moody-Williams, RN, MPP – Deputy Director of the Center for Clinical Standards and Quality at Centers for Medicare and Medicaid Services (CMS)

Ken Moritsugu, MD, MPH, FACPM – Rear Admiral, U.S. Public Health Service (Retired) and Acting Surgeon General of the United States in 2002 and from 2006–2007

Alvin Roth – Professor of Economics at Stanford University and awarded the 2012 Nobel Memorial Prize in Economics

The title of my talk (which Alex Chan and I prepared) is:
Performance Metrics and Regulation of Transplantation

Kidney exchange, in French, in Forbes

Here's a short interview in French about kidney exchange, in Forbes France:

Alvin Roth, Lauréat Du Prix Nobel D’Economie Veut Revolutionner Les Dons De Reins
Philippe Branche   10 janvier 2020

Here's one bit:

Are you currently working with politicians, legislators or medical administrators to resolve this problem ? 

Alvin Roth: I am, but not with great success. I recently spoke to decision makers in several countries: India, China, Germany, Canada and of course the United States. In October, renowned bioethicist Peter Singer expressed strong support for the Global Kidney Exchange Program, so that recently the idea of ​​expanding kidney exchange to include international exchanges has gained momentum. I also recently debated with a member of the Bundestag, the German parliament. In Germany, kidney transplantation from a living donor is legal, but a patient can only receive a kidney from an immediate family member, and therefore the literal interpretation of the law makes it impossible to exchange kidneys. German law provides that monetary exchanges of parts of the human body are illegal and, apparently, it is to avoid any possibility of payment for a kidney that the limitation to family members is applied. A minimal amendment to German law could allow immediate family members to make an indirect donation, via the kidney exchange system, which would preserve the confidence that the donor was not paid to make an exchange. By designing this market in this way, we are trying to expand the database and reduce the waiting time for sick people.

Risk attitudes in transplantation--then and now

Organ transplantation has become much more organized since its early days, for both good and ill.

Today there's a good deal of regulation of transplant centers, which need very high success rates (one year graft survival rates in particular) to remain in the good graces of government and private payers.

It wasn't always so.

Here's a quote from Lloyd Ratner's Message from the ASTS President for November 2019:

"In the transplant world, this [perseverance] is best exemplified by Thomas Starzl’s ceaseless quest to make liver transplantation a reality. Between March 1963 and May 1967, Dr. Starzl performed his first 7 liver transplants at the University of Colorado, all of whom died in the peri-operative period. The longest survivor succumbed after 23 days to “sepsis, bile peritonitis, and liver failure.” Despite this disastrous start, Dr. Starzl persevered. Starzl’s eighth patient, transplanted for hepatocellular carcinoma, lived 400 days before dying from carcinomatosis. By 1990 the programs that Dr. Starzl directed in Pittsburgh would perform 571 liver transplants in a single year and would train many of the world’s leaders in the field."

Reforming stock exchange governance, from the SEC

It's good to know that sometimes the SEC reads papers by market designers (in this case Budish et al.):

Statement on Reforming Stock Exchange Governance by Commissioner Robert J. Jackson Jr., Jan. 8

"As today’s release explains, America’s stock markets are riven by a fundamental conflict of interest: exchanges both operate public data feeds and profit from selling superior private ones.[1] Because exchanges have no economic reason to produce robust public data on stock prices, investors have long demanded a vote on how the public feeds are run.[2] Rather than give investors a real say over the data that drives our markets, today’s release merely invites for-profit exchanges to draft their own rules on these questions. Because that approach has failed investors before, and there’s no reason to expect it to succeed now, I respectfully dissent.

*          *          *          *

In 1934, American investors struck a fundamental bargain with our stock exchanges. The Commission was created to oversee the markets, and nonprofit exchanges were given the special legal status they needed to play a role in protecting ordinary investors.[3] But over a decade ago the deal changed: Exchanges became for-profit entities with powerful incentives to maximize profits, not protect investors.

That’s how we ended up with the two-tiered system for market data we have today. Congress mandated the creation of a public feed when exchanges were still nonprofits, but today’s for-profit exchanges also sell their own private feeds. So it’s unsurprising that exchanges underinvest in the public feed—it’s a product they directly compete with. The only question is what the Commission should do about it. Rather than recognize the reality of the exchanges’ incentives, the Commission today chooses hope over experience, asking exchanges to act contrary to their own economic interests.[4] For two reasons, we should not expect that approach to produce the robust public data that American investors deserve.

First, by proposing an order under a national market system (NMS) plan, we’re asking the exchanges to tell us how best to address the conflicts of interests that currently allow them to profit by controlling the public feed while selling superior private data.[5] No one should be surprised when the exchanges respond that, rather than give investors votes on the operation of the public feed, they’d rather continue controlling it themselves.[6] Instead of a clear solution to an obvious problem, today’s proposal will produce little more than a long process that will benefit lobbyists and lawyers—but not the ordinary investors living with the tax of rising data costs in our markets.[7]

Second, our history governing markets through NMS plans is hardly encouraging. One need look no further than the consolidated audit trail to see what happens when the Commission replaces real regulation with mere hope that stock exchanges will act against their own interests. The CAT was launched in the wake of a terrifying market event nearly a decade ago. Both Chairman Clayton and Director Redfearn have done tremendous work to move it forward. But our predecessors left the construction of the CAT to the NMS process. And the CAT will protect investors, not produce profits. So it’s no surprise that the CAT is still not complete.[8] I hope our successors won’t someday say the same about today’s attempt to reform exchange governance.

*          *          *          *

Those who, like me, are frustrated by today’s failure to require real reform may be tempted to direct their ire towards our stock exchanges. But it’s a mistake to blame private enterprises for maximizing the profit opportunities the law gives them.[9] Instead, we should change the law to address the incentives produced by giving exchanges both control over our public feeds and the opportunity to profit by selling private ones.[10] Without changing those incentives, we cannot and should not expect the market to fix the market.[11]

That’s why I hope commenters will come forward and urge the Commission to do more than merely hope that stock exchanges will act contrary to their private interests. Until we do, our stock markets will continue to fall short of the level playing field that ordinary American investors deserve."

....

"[11] Important recent research shows that, even when the market for trading is perfectly competitive, exchanges can extract supra-competitive rents from selling speed technology in the form of proprietary data feeds. See Eric Budish, Robin S. Lee & John J. Shim, Will the Market Fix the Market? A Theory of Stock Exchange Competition and Innovation, National Bureau of Economic Research Paper No. w25855 (2019)."

Deceased donor organs and nautical miles

UNOS has recently announced a new distribution system for deceased kidney and pancreas offers: instead of being offered first to waiting-list patients at transplant centers in the same one of the 58 Donor Service Areas and then one of the 11 OPTN geographical regions as the donor hospital, they will now be offered first to patients on the waiting lists of transplant centers within 250 nautical miles of the donor hospital.

(Why nautical miles? I don't know, but you can read the various proposals that were considered before deciding on 250 of them at this earlier post: Sunday, May 12, 2019  UNOS proposal for public comment: Eliminate the use of DSAs and regions from kidney and pancreas distribution.)

Here is the new (Dec 5, 2019) announcement: 

New policy adopted to improve kidney, pancreas distribution

"Under the newly approved system, expected to be implemented in 2020, kidney and pancreas offers (except for rare, very well-matched donor and recipient combinations nationwide) will be offered first to candidates listed at transplant hospitals within 250 nautical miles of the donor hospital. Offers not accepted for any of these candidates will then be made for candidates beyond the 250 nautical mile distance.

"Candidates also will receive proximity points based on the distance between their transplant program and the donor hospital. Proximity points are intended to improve the efficiency of organ placement by adding priority for candidates closer to the donor hospital. Candidates within the initial 250 nautical mile radius will receive a maximum of two proximity points, while those outside the initial circle will receive a maximum of four proximity points. The point assignment will be highest for those closest to the donor hospital and will decrease as the distance increases.

"Differences from current system and predicted benefits

"The new system will replace a three-tiered approach used since the beginning of national organ allocation policies in the mid-1980s. Currently, most kidney and pancreas offers go first to candidates listed at hospitals within the same donation service area (DSA) where the donor hospital is located. There are 58 DSAs reflecting the assigned service area of organ procurement organizations (OPOs). These DSAs are fixed, often irregular geographic boundaries, and were not set for the express purpose of optimizing organ allocation. In some instances, portions of the same DSA are not contiguous, meaning that some “local” donor matches may travel through service areas belonging to other OPOs.

"Organ offers not accepted at the DSA level currently are made to candidates at hospitals within the same OPTN region as the donor hospital. Finally, offers not accepted at the DSA or regional level are made to candidates listed at transplant programs anywhere else in the United States.

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

One impetus for the move away from geographic allocation within strict borders is because that system was challenged in the courts, see

Friday, December 29, 2017  The courts take an interest in organ allocation rules

Under the new system, arbitrary borders will no longer have such a big effect on access to transplantation. (Except that is for international borders, which are often still insuperable barriers...)

Fake rhino horn

When is it ok to fight one repugnant transaction with another?  The New York Times has a story of fighting the (repugnant) sales of rhinoceros  horn by flooding the market with fake rhinoceros horn, i.e. fighting the species-endangering trafficking of rhino horn by selling fakes.  Of course the success of such a strategy for reducing poaching depends on whether fakes are a substitute or a complement for the real thing--e.g. it will fail if the fakes increase the size of the market in ways that increases poaching, rather than satisfying the demand more cheaply (or if fear of convincing fakes reduces demand...)

Scientists Created Fake Rhino Horn. But Should We Use It?
Experts are divided over whether flooding the Asian market with convincing artificial rhino horn would help or hurt rhinos’ survival.  By Rachel Nuwer

"In Africa, 892 rhinos were poached for their horns in 2018, down from a high of 1,349 killed in 2015. The decline in deaths is encouraging, but conservationists agree that poaching still poses a dire threat to Africa’s rhino population, which hovers around 24,500 animals.

Now, in the hopes of driving down the value of rhino horn and reducing poaching even more, scientists have created a convincing artificial rhino horn made from horsehair.

... 

Dr. Vollrath believes his artificial horn could be used to covertly flood the market with a cheap, convincing replacement, reducing the demand that leads to rhinos being slaughtered. He also hopes it might provide an educational tool for “demystifying that rhino horn’s something very special,” he said.

...

"Critics say that fake rhino horn risks stimulating demand for real horn, and that it would complicate policing. “There’s already scarce resources for wildlife crime and we don’t want to make it even more difficult for law enforcement,” said Ms. Swaak-Goldman, who works with governments and law enforcement agencies.

Peter Knights, chief executive officer of WildAid, a nonprofit organization dedicated to ending illegal wildlife trade, added that the market in Vietnam is already flooded with convincing fakes, like water buffalo horn, which accounts for up to 90 percent of what’s sold as rhino horn. “It’s widely known that there is a lot of fake product out there, so this experiment is already running,” Mr. Knights said."

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

See also

The Economics of Synthetic Rhino Horns

Chen, Frederick. "The Economics of Synthetic Rhino Horns." Ecological Economics 141 (2017): 180-189.

32 Pages Posted: 24 Aug 2016 Last revised: 10 Aug 2017

Frederick Chen

Wake Forest University

Date Written: June 1, 2017

Abstract

To examine the potential impact of synthetic horns to reduce rhino poaching, a formal model of the rhino horn market in which there exist firms with the capability to produce high quality synthetic horns is presented and studied. The analysis shows that whether the availability of synthetic horns would decrease the equilibrium supply of wild horns -- and how much the reduction would be -- depends on market structure -- i.e., how competitive the synthetic horn production sector is -- and on how substitutable the synthetic horns are for wild horns. The implications of these results for conservation policies are derived and discussed. Synthetic horn producers would benefit more by promoting their products as being superior to wild horns, but this could increase horn prices and lead to more rhino poaching. For conservation purposes, it may be beneficial to incentivize firms to produce inferior fakes -- synthetic horns that are engineered to be undesirable in some respect but difficult for buyers to distinguish from wild horns. The analysis also shows that promoting competition in the production of synthetic horns in general is desirable from a conservation standpoint as synthetic horn producers may prefer to keep prices at a high enough level that could still encourage significant amount of poaching.

Social studies of markets, marketplaces, and market design in the journal Economy and Society

Economists aren't the only social scientists who study markets and market-like institutions and organizations, and some of the study of markets by non-economists falls under the loose heading of 'Social studies of markets'.

The Journal Economy and Society  has a special issue on Markets for Collective Concerns and their Failures (Volume 48, 2019 - Issue 2).

The articles in the issue focus both on the social study of markets per se, and on critiquing the way such studies are conducted.

The introductory article, "The organization of markets for collective concerns and their failures," by Christian Frankel, José Ossandón & Trine Pallesen, all professors in the Department of Organization at Copenhagen Business School. summarizes the object of study by noting that
"Sociologists of different traditions share the view that part of their task is to provide definitions of markets." (emphasis added).

The concluding article, "On going the market one better: economic market design and the contradictions of building markets for public purposes,"  by Edward Nik-Khah and Philip Mirowski, criticizes social scientists for not taking sufficient account of market design, and criticizes market design for transforming markets from general purpose natural institutions into specialized human artifacts.

I find the level of abstraction in some of this work hard to follow. I guess I take it for granted that different markets are different, and that markets and marketplaces are (and always have been) human artifacts. (I agree though that sometimes other, more abstract simple views have held sway even among economists, and so I also agree that market design can take a bow for at least helping to add some nuance to the view that markets are simply emergent phenomena that arise without human intervention...)

But academic ideas influence popular ideas, and abstract ideas about markets have consequences. To paraphrase Keynes, I think it is sometimes the case that 'Practical men who believe themselves to be quite exempt from any intellectual influence,' are sometimes influenced by ideas about "markets" in the abstract.  So I'll probably continue to try to follow this kind of work, although I'm often disappointed that it doesn't help me to better understand markets and marketplaces and their roles in society.

Here's the table of contents of the special issue.

Article The organization of markets for collective concerns and their failures Christian Frankel, José Ossandón & Trine Pallesen Pages: 153-174 Published online: 16 Jul 2019 Abstract|Full Text|References| PDF (412 KB) | 564Views 0CrossRef citations 4Altmetric

Article Problematizing markets: market failures and the government of collective concerns José Ossandón & Sebastián Ureta Pages: 175-196 Published online: 16 Jul 2019 Abstract|Full Text|References| PDF (390 KB) | 346Views 0CrossRef citations 2Altmetric

Article Making an exception: market design and the politics of re-regulation in the French electricity sector Thomas Reverdy & Daniel Breslau Pages: 197-220 Published online: 17 Jul 2019 Abstract|Full Text|References| PDF (255 KB) | 270Views 0CrossRef citations 9Altmetric

Article Carving out a domain for the market: boundary making in European environmental markets Liliana Doganova & Brice Laurent Pages: 221-242 Published online: 19 Jul 2019 Abstract|Full Text|References| PDF (201 KB) | 243Views 0CrossRef citations 2Altmetric

Article On the difficulties of addressing collective concerns through markets: from market devices to accountability devices Daniel Neyland, Véra Ehrenstein & Sveta Milyaeva Pages: 243-267 Published online: 05 Jul 2019 Abstract|Full Text|References| PDF (217 KB) | 290Views 0CrossRef citations 0Altmetric

Article On going the market one better: economic market design and the contradictions of building markets for public purposes Edward Nik-Khah & Philip Mirowski Pages: 268-294

ASSA meetings--Sunday market design

Behavioral Market Design
Paper Session
 Sunday, Jan. 5, 2020   1:00 PM - 3:00 PM
 Marriott Marquis San Diego, Point Loma
Hosted By: AMERICAN ECONOMIC ASSOCIATION
Chair: Shengwu Li, Harvard University

Expectations-Based Loss Aversion May Help Explain Seemingly Dominated Choices in Strategy-Proof Mechanisms
Bnaya Dreyfus, Hebrew University of Jerusalem
Ori Heffetz, Cornell University and Hebrew University
Matthew Rabin, Harvard University

Correlation Neglect in Student-To-School Matching
Alex Rees-Jones, University of Pennsylvania
Ran Shorrer, Pennsylvania State University
Chloe Tergiman, Pennsylvania State University

School Choice with Limited Attention
Modibo Sidibe, Duke University
Kehinde Ajayi, World Bank

Obvious Manipulations
Peter Troyan, University of Virginia
Thayer Morrill, North Carolina State University
 View Abstract

ASSA Market Design on Saturday

Matching under Inequality: Implications for Policy
Paper Session
 Saturday, Jan. 4, 2020   8:00 AM - 10:00 AM (PST)
 Marriott Marquis San Diego, Marriott Grand Ballroom 4
Hosted By: AMERICAN ECONOMIC ASSOCIATION
Chair: Raj Chetty, Harvard University

Trade and Inequality across Local Labor Markets: The Margins of Adjustment
Ryan Kim, Johns Hopkins University
Jonathan Vogel, University of California-Los Angeles

College Admissions at Selective Schools
Raj Chetty, Harvard University
David Deming, Harvard University
John N. Friedman, Brown University

Redistribution in Matching Markets
Mohammad Akbarpour, Stanford University
Piotr Dworczak, Northwestern University
Scott Duke Kominers, Harvard Business School

Capital Mismatch and the Form of Capital Taxation
Ravi Jagadeesan, Harvard Business School

Discussant(s)
Costas Meghir, Yale University
Lawrence Blume, Cornell University
Piotr Dworczak, Northwestern University
*************
Algorithmic Fairness and Bias
Paper Session
 Saturday, Jan. 4, 2020   10:15 AM - 12:15 PM (PST)
 Marriott Marquis San Diego, Marriott Grand Ballroom 1
Hosted By: AMERICAN ECONOMIC ASSOCIATION
Chair: Bo Cowgill, Columbia University

Designing Organizations and Incentives with Human and Artificial Intelligence Agents
Susan Athey, Stanford University
Kevin Bryan, University of Toronto
Joshua Gans, University of Toronto

Biased Programmers? Or Biased Data? A Field Experiment in Operationalizing AI Ethics
Bo Cowgill, Columbia University
Fabrizio Dell'Aqua, Columbia University

Regulating Discrimination in the Presence of Algorithms
Jon Kleinberg, Cornell University
Jens Ludwig, University of Chicago
Sendhil Mullainathan, University of Chicago
Ashesh Rambachan, Harvard University

Algorithmic Risk Assessment in the Hands of Humans
Megan Stevenson, George Mason University
Jennifer Doleac, Texas A&M University

Discussant(s)
Joshua Gans, University of Toronto
Avi Goldfarb, University of Toronto
Jorge Guzmán, Columbia University
Shane Greenstein, Harvard Business School