New policy stops transplant heart gaming but potential still exists

New policy stops transplant heart gaming but potential still exists

University Park, Pa. -- Researchers have found evidence of gaming -- exaggerating the severity of a heart patient's condition -- at heart transplant centers prior to 1999 to increase the likelihood of obtaining a transplant organ, but not after that year when new policies governing the patient waiting list went into effect.

Dennis Scanlon, assistant professor of health policy and administration at Penn State, says, "Although we did not find evidence of gaming after 1999, suggesting that the new policy regulates the system competently, the competition driving gaming still exists. We need to remain vigilant because the continued competition for scarce transplantable organs could encourage new kinds of gaming."

The findings are published in the paper, "Does Competition for Transplantable Hearts Encourage 'Gaming' of the Waiting List," in the March/April issue of Health Affairs. The authors are Scanlon; Christopher S. Hollenbeak, assistant professor of surgery and health evaluation sciences, Penn State College of Medicine; Woolton Lee, doctoral candidate in health policy and administration, Penn State College of Health and Human Development; Evan Loh, assistant vice president of cardiovascular/infectious disease, Wyeth Corp.; and Peter A. Ubel, associate professor of internal medicine and psychology, University of Michigan, and director of the U-M Health System's Program for Improving Health Care Decisions.

Currently, demand exceeds the supply of transplantable hearts in the United States. In 2003, 3,517 people were on the waiting list, compared with 1,174 heart transplants performed, according to the United Network for Organ Sharing (UNOS), which develops allocation procedures and maintains lists that give priority to the sickest patients.

Organ Procurement Organizations (OPO) obtain and disperse the transplantable hearts within a specific geographical region. Since long transport could damage cadaver hearts, organs obtained in an OPO are used primarily within the geographical boundaries of that same OPO. Some OPOs have only one heart transplantation center within its boundaries while others have up to nine centers that must compete for organs.

Before the 1999 rule change, patients awaiting heart transplants were listed in one of two categories, with the highest priority for those expected to live less than six months without a transplant.

"In areas with more than one heart transplant center, this left a high possibility of the exaggeration of patients' conditions or even the admission of patients to an ICU prematurely in order to boost their chances of receiving a transplant," says Ubel.

Using standard tests to measure competition and market share, the researchers examined aggregate patient waiting list data from all 55 of the U.S. OPOs for the years 1995 to 2000. The Justice Department and Federal Trade Commission use the same tests in antitrust proceedings.

The researchers compared the proportion of patients listed in the sickest category in OPOs where there is no competition with those where competition exists. They found that, prior to UNOS' policy change in 1999, heart transplant centers in competitive OPOs were more likely to list their patients in the sickest category than centers in less competitive OPOs, suggesting gaming.

After the rule change, the researchers found, the more competitive transplants centers did not have higher numbers of patients listed in either of the two highest priority levels.

"Centers may prematurely admit patients to ICUs to elevate them on the waiting list. This not only has economic implications but also could harm patients by subjecting them to unnecessary medical procedures," Ubel notes.

Scanlon adds, "The new heart patient waiting list policies that reduce ambiguity and discretion appear to be effective regulators. But there is a need to continue to monitor the system carefully. Tightening rules for other organs where competition is intense may also be necessary particularly in light of recent lawsuits alleging gaming in liver transplant centers."