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.
Customer is defined as someone who purchases goods or services. In this case, the customer is CMS and the answer to the question posed is yes, it is better for the customer to pay for 60 and have 59 succeed.
ReplyDeleteLet’s see if I can summarize this situation using the Froeb problem-solving algorithm.
ReplyDelete1. Who is making a bad decision?
Physicians are not full utilizing usable kidney organs.
2. Does the decision maker have enough information to make a good decision?
No. Physicians are getting inconclusive information and become hesitant to move forward with a usable kidney organ.
3. Does that decision maker have the incentive to make a good decision?
There is no more absolute incentive than patient survival rates.
It’s clear that the crux of the issue is information. Doctors aren’t getting the information they need. Information systems are outdated and do not have improved matching algorithms. I actually wonder if the physicians are actually the decision makers themselves if they are only following formulistic set of guidelines. In which case, the “system” is the ultimate decision maker. If that is the case, the information problem becomes compounded when the ‘”system” (not physicians) do not have a direct incentive.
Hence, as Froeb mentioned, if there was a true legal free market for this with incentives, information accuracy and quality will make leaps and bounds. Pushing for a “dialysis” of the current system might just take too long with patient lives on the line.
CMS is making the decisions regardless of how much information they have. And they are incentivized to do what is in THEIR best economic interest.
ReplyDeleteInformation has little to do with the problem. It is clearly in the best interest of CMS to pay for 60 transplants and have 59 be successful as opposed to paying for 100 where only 88 are successful.
The other 29 don't get a kidney because it's too expensive, as determined by CMS. If you only transplant the ones with the highest success rate, your failure rate is 1 in 60, meaning that, for each successful transplant, CMS pays 1 1/59 their standard payment. But, if you go ahead and accept a lower success rate in an attempt to help the other 29 people, your cost becomes 1 3/22 per successful transplant.
The cost, therefore, is 12% more per patient in order to save the lives of 29 additional people per every 100 transplants.
CMS has apparently made the decision that the additional lives saved are not worth the additional expenditure.
I realize that is seems wasteful, and possibly even unethical, to be throwing away kidneys when their are so many people in need of them. However, this article is explaining that with physicians being more selective with the kidneys, the success rate has improved. Therefor, would t be better to have them use more kidneys and have a lower success rate? I know that is I were on a transplant list, I would rather wait and have a good chance of the organ transplant being a success, rather than just taking the next available one
ReplyDeleteI realize there is some incentive for the physicians to "manipulate" these results by being more selective with which kidneys are kept. However, should they be less selective when there are lives at stake?
I realize that is seems wasteful, and possibly even unethical, to be throwing away kidneys when their are so many people in need of them. However, this article is explaining that with physicians being more selective with the kidneys, the success rate has improved. Therefor, would t be better to have them use more kidneys and have a lower success rate? I know that is I were on a transplant list, I would rather wait and have a good chance of the organ transplant being a success, rather than just taking the next available one
ReplyDeleteI realize there is some incentive for the physicians to "manipulate" these results by being more selective with which kidneys are kept. However, should they be less selective when there are lives at stake?
A better success rate, as illustrated, can actually mean that FEWER patients are helped. How is that a good thing? And, more importantly, shouldn't the patient be making the decision rather than CMS?
ReplyDeleteProfessor Froeb,
ReplyDeleteThe game just changed a little but nowhere near what you proposed in class: http://www.modernhealthcare.com/article/20151220/NEWS/312209999
I guess there is still an opportunity for one of us students to go open up our transplant center on a vessel in international waters.....
Nathan Rave
Wow, to think last year that 4,720 people died while waiting for kidney transplants in the U.S, and more than 2,600 kidneys were recovered from deceased donors, and then discarded without being transplanted is just plan awful.
ReplyDeleteIn my opinion, I believe that a significant number of discarded kidneys, could have been transplanted if the system for allocating them better matched the right organ to the right recipient in the right amount of time. It is the end of year 2015, and no one has been able to redesign or update the outdated computer matching system.
I really saddens my heart to read Dr. Dorry Segev, a transplant surgeon at Johns Hopkins University School of Medicine comment “There is no doubt that organs that can help somebody and have a survival benefit are being discarded every day”.
This is an example of Principal want agents to work in the principals’ best interests, but agent typically have different goals from those of principals’. This is called incentive conflict. Incentive conflict and asymmetric information leads to moral hazards and adverse selection.
It’s clear that the core of the matter is that the doctors are not getting the necessary information they require. The set of Information Systems available are outmoded leading to the wasting of Kidneys when there are a lot of people who need them . Also, it is not clear if the physicians are following guidelines or actually the decision makers.
ReplyDeleteThis can be likened to the dreadful "credit default swap" that devastated the entire economy in 2008. The seller of the contract assumes the credit risk that the buyer does not wish to shoulder in exchange for a periodic protection fee. The buyer gains protection or earn a profit when the issuer has a negative credit event.
If such an event occurs, the issuer who has assumed the credit risk, must deliver the value of principal and interest payments that the reference bond would have paid to the buyer. Credit default swaps are not unlike me being able to insure assets, so that if your house is washed away in the next hurricane I get paid its value.
It's bad enough that these subprime "Kidney pools" that "Kidney investment banks" are mishandled and ended up falling precipitously.