Kidney Holdup

Its seems that, back in 2012, a woman was fired by her boss soon after she donated her kidney to her boss ... because she was taking too long recuperating from the donation.

“I feel very betrayed. This has been a very hurtful and horrible experience for me. She just took this gift and put it on the ground and kicked it.’’

It seems she was hired, or rehired, so as to obtain access to her kidney. She had an implicit expectation that she would have continued employment post-donation. But after the operation, the decision was sunk and created a holdup opportunity.

Of course, she sued and apparently she lost. This may not have happened if selling a kidney were legal and she could have contracted for compensation. A market would likely have other benefits as it moves assets (kidneys) from low values uses (essentially "spare parts" in healthy bodies) to higher valued uses (bodies with nonfunctional kidneys).

Wouldn't a market be much simpler?

Anyone who reads this blog knows that there are more than 60,000 patients who want a kidney; and less than 20,000 donors (cadaver and live). Attempts to create individual "matching" markets are extremely cumbersome, and fraught with problems of trust and verification:

US doctors have carried out what is believed to be the world's first simultaneous six-way kidney transplant.

Six recipients received organs from six donors in operations at the Johns Hopkins Hospital in Maryland.

The procedure was made possible after an altruistic donor - neither a friend nor relative of any of the six patients - was found to match one of them.

Five patients had a willing donor whose kidney was incompatible with theirs, but it did match another in the group.

This meant that suddenly, there were six people who could receive an organ.

The operations were carried out simultaneously to make sure no-one backed out after their loved one had received a kidney.

REPOST: Kidney Hold-up

Its seems that, back in 2012, a woman was fired by her boss soon after she donated her kidney to her boss ... because she was taking too long recuperating from the donation.

“I feel very betrayed. This has been a very hurtful and horrible experience for me. She just took this gift and put it on the ground and kicked it.’’

It seems she was hired, or rehired, so as to obtain access to her kidney. She had an implicit expectation that she would have continued employment post-donation. But after the operation, the decision was sunk and created a holdup opportunity.

Of course, she sued and apparently she lost. This may not have happened if selling a kidney were legal and she could have contracted for compensation. A market would likely have other benefits as it moves assets (kidneys) from low values uses (essentially "spare parts" in healthy bodies) to higher valued uses (bodies with nonfunctional kidneys).

Why do kidney prices vary so much?

An Aussie physician suggests paying $47,000/kidney. In an earlier post, we reported that Iran pays kidney donors less than $1,200. So why is the proposed price so high in Australia?

Australia has one of the lowest rates of organ donation in the developed world, about 10 donors per 1 million people, according to a federal health task force. ... In comparison, Germany has 15 donors per 1 million people, the Netherlands has 25, the United States 27, and Spain 35...

"We've tried everything to drum up support for organ donation and the rates have not risen in 10 years," Carney was quoted as saying in Fairfax newspapers. "People just don't seem to be willing to give their organs away for free. ... Let's pay people some money for a new car or a house deposit and those waiting lists will be halved within about five years."

More on Paying for Kidney Donations

We've blogged a number of times on the shortage of kidney donations and laws against paying donors. As discussed in this recent Slate article, The American Medical Association has apparently adopted our view - the Association recently voted to lobby Congress to allow the study of the use of some sort of financial incentives for donating organs.

Unfortunately, the National Kidney Foundation will not support this effort. According to a senior vice president for health policy and research with the organization, financial payments would cheapen the gift and lead to fewer people donating overall. We need to track this person down and send them a copy of our book.

Advertising for Kidneys

Need a kidney? Consider trying Craigslist. That's the solution one family turned to given the huge mismatch between demand and supply for kidneys.

"Please help us, my dad needs a kidney!" began their posting in the site's volunteer section. The Floods received more than 100 responses to the Craigslist ad. Many sounded genuinely interested in helping, but others sought to sell a kidney, which is illegal in the United States.

More on Kidney Donations

The low supply of donor kidneys relative to demand is a recurring theme on our blog. Here's Virginia Postrel in The Atlantic on the need for more creative solutions. An excerpt on the issue of paying donors:

The obvious solution to the problem of barter is, of course, money. Altruistic blood donors often receive freebies like movie tickets or paid vacation hours that would be illegal for kidney donors. Plasma and sperm donors routinely receive cash, as do egg donors and surrogate mothers, who get tens of thousands of dollars.. If transplant centers could pay $25,000 or $50,000 to each living kidney donor, many more people would line up to contribute.

Such payments could even save taxpayers billions of dollars. Long-term dialysis is a federal entitlement. Under a special law, Medicare covers everyone, regardless of age, who has made minimal Social Security tax payments—about 319,000 of the country’s 400,000 dialysis patients. Compared with dialysis payments, every transplant from a living, unrelated donor saves an expected present value of almost $100,000 in medical costs, according to a 2003 American Journal of Transplantation article by Matas and Mark Schnitzler, an economist then at Washington University in St. Louis and now at the Saint Louis University Center for Outcomes Research.

Eliminating the waiting list would thus save taxpayers $8 billion, or $4 billion if each living donor received a lump-sum payment of $50,000.

Want a kidney? Wait six years.

In our textbook, one of our best money making ideas is selling kidneys:

If I can borrow $100 million at 20% interest, I can buy a hospital ship, anchor it in international waters, and begin selling kidneys. I can set up a database to match donors to recipients, broker sales, and fly in experienced transplant teams. If I charge $200,000 and earn 10% on each transaction, the break-even quantity is just 1,000 transplant each year. This represents about 1% of the potential demand in the United States alone.

Now the Wall St. Journal reports that since the waiting list has grown to six years, there is growing support for lifting the federal law that led to the shortage:

Dr. Matas, 59 years old, is a Canadian-born physician... [has]...been traveling the country trying to make the case that barring kidney sales is tantamount to sentencing some patients to death.
...
The federal ban on organ sales dates back to 1983, when Virginia physician Dr. H. Barry Jacobs proposed buying kidneys -- mostly from the indigent -- and selling them to whomever could afford to buy. His plan was met with widespread outrage. In Congress, then-Rep. Al Gore (D., Tenn.) introduced legislation banning the sale of organs. The bill became law in 1984.

No kidney shortage in Iran

Iranian kidney vendors are paid in two ways.

1. the Iranian government provides a fixed compensation to the vendor of approximately $1,200 plus limited health insurance coverage, which currently extends to one year after the exchange and covers only conditions deemed related to the surgery
   
2. the vendor receives separate remuneration either from the recipient or, if the recipient is impoverished, from one of a series of designated charitable organizations; this amount is usually between $2,300 and $4,500

Iranian kidney sales

Interesting documentary about kidney markets in Iran (60 minutes).

$2000/kidney in the Phllipines

Kidney sales are illegal in the Phillipines but this CNN video documents a thriving black market. A surprising policy proposal to help the donors.

Why are so many donated kidneys discarded?

In the past, we have blogged about our inefficient kidney matching system:  almost 100,000 people are waiting for kidneys, only about 20,000 receive kidneys. 

Now we learn that physicians throw away about 2000 usable kidneys.  One of the reasons is the government's performance evaluation metric:  If the number of failures exceeds expected levels by 50 percent, transplant programs are put on watch list, and then decertified if they dont improve.  This incentive encourages physicians to reject all but the best organs for transplant:

“When you’re looking at organs on the margins, if you’ve had a couple of bad outcomes recently you say, ‘Well, why should I do this?’ ” said Dr. Lloyd E. Ratner, direct of renal and pancreatic transplantation at NewYork-Presbyterian/Columbia hospital. “You can always find a reason to turn organs down. It’s this whole cascade that winds up with people being denied care or with reduced access to care.” 

After the University of Toledo was cited, a transplant surgeon cut back to about 60 transplants a year from 100, becoming far choosier about the organs and recipients he accepted. 

The one-year transplant survival rate rose to 96 percent from 88 percent, but Dr. Rees still bristles at the trade-off. “Which serves America better?” he asked. “A program doing 100 kidneys and 88 percent of them are working, or a program that does 60 kidneys and 59 of them are working? It’s rationing health care under the guise of quality, and it’s a tragedy that we are throwing away perfectly good organs.”

Someone, please, let these people use a market. 

Legal Markets in Kidneys

Q: What bastion of free market liberalism has virtually eliminated the waiting list for kidneys and dramatically reduced deaths due to kidney failure?

A: Iran

REPOST: why are so many donated kidneys discarded?

Thursday, September 20, 2012

Why are so many donated kidneys discarded?

In the past, we have blogged about our inefficient kidney matching system:  almost 100,000 people are waiting for kidneys, only about 20,000 receive kidneys.

Now we learn that physicians throw away about 2000 usable kidneys.  One of the reasons is the government's performance evaluation metric:  If the number of failures exceeds expected levels by 50 percent, transplant programs are put on watch list, and then decertified if they dont improve.  This incentive encourages physicians to reject all but the best organs for transplant:

“When you’re looking at organs on the margins, if you’ve had a couple of bad outcomes recently you say, ‘Well, why should I do this?’ ” said Dr. Lloyd E. Ratner, direct of renal and pancreatic transplantation at NewYork-Presbyterian/Columbia hospital. “You can always find a reason to turn organs down. It’s this whole cascade that winds up with people being denied care or with reduced access to care.” 

After the University of Toledo was cited, a transplant surgeon cut back to about 60 transplants a year from 100, becoming far choosier about the organs and recipients he accepted. 

The one-year transplant survival rate rose to 96 percent from 88 percent, but Dr. Rees still bristles at the trade-off. “Which serves America better?” he asked. “A program doing 100 kidneys and 88 percent of them are working, or a program that does 60 kidneys and 59 of them are working? It’s rationing health care under the guise of quality, and it’s a tragedy that we are throwing away perfectly good organs.”

Someone, please, let these people use a market. 

Clergy facilitate the movement of kidneys to higher valued uses

With over 100,000 people waiting for a kidney, and only 8,000 supplied by accident victims, the US black market flourishes.

By accident or by design, she believed, surgeons in their unit had been transplanting black-market kidneys from residents of the world's most impoverished slums into the failing bodies of wealthy dialysis patients from Israel, Europe and the United States. According to Scheper-Hughes, the arrangements were being negotiated by an elaborate network of criminals who kept most of the money themselves. For about $150,000 per transplant, these organ brokers would reach across continents to connect buyers and sellers, whom they then guided to "broker-friendly" hospitals here in the United States (places where Scheper-Hughes says surgeons were either complicit in the scheme or willing to turn a blind eye). The brokers themselves often posed as or hired clergy to accompany their clients into the hospital and ensure that the process went smoothly. The organ sellers typically got a few thousand dollars for their troubles, plus the chance to see an American city.

Odd role that clergy play in this drama.

Recessions are good for us

Even as people are worrying more, they're smoking, drinking and driving less:

...in certain ways, health does worsen in times of economic uncertainty. Medical science has accumulated a solid body of research showing that poverty and unemployment lead to higher rates of obesity and more cases of diabetes, asthma, kidney disease, cardiovascular disease, some cancers -- the list goes on.

But strange as it may seem, bad times can also be good for health. Forget individual health for a minute. This is about the macro picture, the health of entire societies. And there statistics show that as economics worsen, traffic accidents go down, as do industrial accidents, obesity, alcohol consumption and smoking. Population-wide, even deaths from heart disease go down during recessions.

Wouldn't a market be much simpler?

In the spring of 2011, Rick Ruzzamenti of Riverside California decided to donate his kidney to a orgnization set up to match donors and recipients. His selfless act set off a domino chain of 60 operations involving 17 hospitals in 11 different states. Donors, unable to help their loved ones because of incompatible blood types or antibodies, instead donated kidneys to those whose loved ones donated to others, and so on, until the chain ended six months later in Chicago, Illinois.

The good news is that thirty people received new kidneys, and escaped the "living hell" of dialysis. The bad news is that this complex barter system is the only legal way for Americans to get kidneys. It is so inefficient that only 17,000 of the 90,000 people on waiting lists received kidneys last year.

To understand how complex and cumbersome this process is, imagine trying to do the same things with an apartment . If you wanted to move from Detroit to Nashville, you would either have to find someone who was moving in the opposite direction or, failing that, you could find a second person moving from Nashville to Los Angeles, and a third from Los Angeles to Detroit.  Then you could swap the first apartment for the second, the second for the third, and the third for the first.

Why not simply allow people to buy and sell kidneys?

How Much is a Year of Your Life Worth?

Now where do you think you could find an answer to such a ridiculous question? Ask an economist, of course.

Time magazine reports:

Stanford economists have demonstrated that the average value of a year of quality human life is actually closer to about $129,000. To get to that number, Stefanos Zenios and his colleagues at Stanford Graduate School of Business used kidney dialysis as a benchmark.

To tally the cost-effectiveness of such innovations Zenios and his colleagues ran a computer analysis of more than half a million patients who underwent dialysis, adding up costs and comparing that data to treatment outcomes. Considering both inflation and new technologies in dialysis, they arrived at $129,000.

"That means that if Medicare paid an additional $129,000 to treat a group of patients, on average, group members would get one more quality-adjusted life year," Zenios says. Based on patient surveys, one "quality of life" year is defined as about two years of life on dialysis.

Why are kidneys more likely to discarded on weekends?

New study shows that usable kidneys are discarded at 29% higher rates on Friday and at 25% higher rates on Saturday, holding kidney quality constant.  Furthermore the discarded kidneys were of higher quality than those discarded during the week.

Since 5000 people die waiting for kidneys each year, it is probably not due to lack of demand.

I will award an autographed copy of the fourth edition textbook to anyone who can solve this puzzle.  To enter, post your solution in the comment section. (I don't know the answer).

REPOST: Why are so many donated kidneys discarded?

In the past, we have blogged about our inefficient kidney matching system:  almost 100,000 people are waiting for kidneys, only about 20,000 receive kidneys.

Now we learn that physicians throw away about 2000 usable kidneys.  One of the reasons is the government's performance evaluation metric:  If the number of failures exceeds expected levels by 50 percent, transplant programs are put on watch list, and then decertified if they dont improve.  This incentive encourages physicians to reject all but the best organs for transplant:

“When you’re looking at organs on the margins, if you’ve had a couple of bad outcomes recently you say, ‘Well, why should I do this?’ ” said Dr. Lloyd E. Ratner, direct of renal and pancreatic transplantation at NewYork-Presbyterian/Columbia hospital. “You can always find a reason to turn organs down. It’s this whole cascade that winds up with people being denied care or with reduced access to care.” 

After the University of Toledo was cited, a transplant surgeon cut back to about 60 transplants a year from 100, becoming far choosier about the organs and recipients he accepted. 

The one-year transplant survival rate rose to 96 percent from 88 percent, but Dr. Rees still bristles at the trade-off. “Which serves America better?” he asked. “A program doing 100 kidneys and 88 percent of them are working, or a program that does 60 kidneys and 59 of them are working? It’s rationing health care under the guise of quality, and it’s a tragedy that we are throwing away perfectly good organs.”

Someone, please, let these people use a market.