The government contracts with, and ‘supervises,’ a network of nonprofits in a sadly chaotic, inefficient, dishonest, and unfair system to allocate scarce transplant organs. The government has set up perverse incentives, with unintended consequences, by telling the nonprofits that they will be evaluated on the basis of not wasting organs; those evaluated badly will not have their contracts renewed. So they have an incentive to get the organs out the door quickly, even if they do not go to patients higher on the waiting list. Hospitals know they will be evaluated on the basis of how many transplanted patients survive at least a year. So they have an incentive to reject below average organs, and, when they get above average organs, to ignore the waiting list, in order to transplant them into the most healthy patients.
The result is that the sickest and those who have waited the longest are frequently skipped over, instead of receiving the organ when it is their turn.
Why don’t we try something bold–allow for-profit entrepreneurs to engage in medical institutional innovation? For instance, if we allow it, one medical entrepreneurs might purchase from willing donors the right to allocate their organs if and when they become available. Another medical entrepreneur might set up an institution appealing to donors who do not want to be paid, but do want a guarantee that their organs will go to the poor at no charge.
In retailing Walmart and Amazon have different models, but both made major logistical innovations. We need a Walmart and an Amazon of organ transplantation. We need market-tested innovation (as Deirdre McCloskey might say).
Allowing some donors to be paid will reduce the scarcity of organs, which is the most basic constraint on this issue. Innovative medical entrepreneurs may find other ways to loosen this most basic constraint, such as mechanical organs, regrowing human organs from stem cells, and growing transplantable organs in pigs.
(p. A1) For decades, fairness has been the guiding principle of the American organ transplant system. Its bedrock, a national registry, operates under strict federal rules meant to ensure that donated organs are offered to the patients who need them most, in careful order of priority.
But today, officials regularly ignore the rankings, leapfrogging over hundreds or even thousands of people when they give out kidneys, livers, lungs and hearts. These organs often go to recipients who are not as sick, have not been waiting nearly as long and, in some cases, are not on the list at all, a New York Times investigation found.
Last year, officials skipped patients on the (p. A10) waiting lists for nearly 20 percent of transplants from deceased donors, six times as often as a few years earlier. It is a profound shift in the transplant system, whose promise of equality has become increasingly warped by expediency and favoritism.
Under government pressure to place more organs, the nonprofit organizations that manage donations are routinely prioritizing ease over fairness. They use shortcuts to steer organs to selected hospitals, which jockey to get better access than their competitors.
. . .
The Times analyzed more than 500,000 transplants performed since 2004 and found that procurement organizations regularly ignore waiting lists even when distributing higher-quality organs. Last year, 37 percent of the kidneys allocated outside the normal process were scored as above-average. Other organs are not scored in the same way, but donor age is often used as a proxy for quality, and data shows there is little difference in the age of organs allocated normally compared with those that are not.
And while many people in the transplant community believe ignoring lists is reducing organ wastage, there is no evidence that is true, according to an unreleased report by a group of doctors and researchers asked by the transplant system last year to study the practice.
. . .
In 2020, procurement organizations felt under attack. Congress was criticizing them for letting too many organs go to waste. Regulators moved to give each organization a grade and, starting in 2026, fire the lowest performers.
They scrambled to respond. They assigned more staff to hospitals to identify donors, grew more aggressive with families and recovered more organs from older or sicker donors.
Those steps increased donations and transplants, dozens of employees said. Both hit record highs last year, when there were 41,115 transplants.
At the same time, the organizations increasingly used a shortcut known as an open offer. Open offers are remarkably efficient — officials choose a hospital and allow it to put the organ into any patient.
. . .
Some procurement organizations sidestep the list because they believe it helps them place more organs. But it can also help their bottom lines.
In 2021, the South Carolina procurement organization phased out its allocation team and handed the task to workers who were already managing donors, testing organs and helping with surgeries. As a workaround, three former employees said, executives created a spreadsheet with preferred doctors’ phone numbers.
If the employees were too busy to do allocation, they said, they were told to give open offers to those doctors.
“They’d tell me to get rid of the organs quickly, so I could be done,” said Aron Knorr, one of the former workers, who said the directive made him uncomfortable.
. . .
Dr. Alghidak Salama, who led South Florida’s organization until August [2024], said open offers were financially beneficial: When organizations distribute organs, they are paid a set fee by receiving hospitals, regardless of what costs they incur. Speeding up allocation (p. A11) saves money on staffing.
. . .
When hospitals get open offers, they often give organs to patients who are healthier than others needing transplants, The Times found. For example, 80 percent of all donated hearts in recent years went to patients sick enough to be hospitalized, records show. But when lists were skipped, it was less than 40 percent.
Healthier patients are likelier to help transplant centers perform well on one of their most important benchmarks: the percentage of patients who survive a year after surgery. The government monitors that rate, as do insurers, which can decline to pay low-performing hospitals.
. . .
Federal regulators have known since 2022 that more people were being skipped, according to meeting notes obtained by The Times. But until last week, they had done little to address it.
The U.S. Centers for Medicare & Medicaid Services monitors hospitals and procurement organizations. The Health Resources and Services Administration tracks the system overall. But for years, they deferred to UNOS.
Records show that when the system’s oversight committee reviews instances of bypassed patients, it closes more than 99.5 percent of cases without action, usually concluding that the organ was at risk of going to waste. In the last five years, the committee has never gone further than sending “notices of noncompliance,” the mildest action it can take.
“The oversight is almost nonexistent, and that’s been true basically forever,” said Dr. Seth Karp, a Vanderbilt University surgeon who served on the committee, which he noted is largely made up of transplant doctors and procurement officials policing themselves.
For the full story see:
Brian M. Rosenthal, Mark Hansen and Jeremy White. “Organ Transplant System ‘in Chaos’ As Waiting Lists Are Ignored.” The New York Times (Monday, March 10, 2025): A1 & A10-A11.
(Note: ellipses, and bracketed year, added.)
(Note: the online version of the story has the date Feb. 26, 2025, and has the same title as the print version.)
