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Voices & Opinion

POV: Our Organ Donation System Is Broken. Here’s What We Need to Do to Fix It

The problem begins with improving the performance of local organ procurement organizations

The United States just passed a law to update its organ donation network for the first time in 40 years. But will it fix what’s really broken?

The country’s organ donation system, congressionally mandated in 1984, is called the Organ Procurement and Transplantation Network (the network). It connects individual transplant programs across the country, allowing more donor organs to reach patients in need.

When created, it was mandated that the network be run by a single private entity. An organization called the United Network for Organ Sharing (UNOS) won the federal contract in 1986 and has had full control over the network without competition ever since.

Critics have long held that the UNOS monopoly of the network has resulted in complacency and error. Congress finally listened, and in 2023, passed the Securing the United States Organ Procurement and Transplantation Network Act to allow the federal government to contract with multiple organizations at once to run the network.

The new competition is intended to improve operational efficiency and increase the number of annual transplants. But the new law doesn’t actually address the most dysfunctional part of the network: the local organ procurement organizations (OPOs) that carry out day-to-day operations.

OPO underperformance and patient impacts

Currently, 56 OPOs around the country coordinate the procurement, transport, and transplantation of thousands of organs and tissues each year. Each OPO operates within an exclusive designated service area. For example, the Midwest Transplant Network OPO coordinates for all of Kansas and much of Missouri, while the Lifebanc OPO serves just 20 counties in Ohio.

OPOs face no competition from each other and little regulation from UNOS or the Centers for Medicare & Medicaid Services (CMS), which oversee them. Unfortunately, in this case, light regulation has had dire consequences.

A 2022 Senate report outlined a series of worrisome lapses in operational and procedural conduct by OPOs. In 2020, one OPO threw a recently procured kidney in the trash, rendering it unsterile and unusable. Even more alarming, in both 2017 and 2018, two different OPOs oversaw organ retrieval on donors who were still alive upon surgical entry into the chest cavity. One of these cases was raised to UNOS by an anonymous reporter, but was dismissed by the organization.

In fact, only 40 percent of claims like these are referred up the chain within UNOS for additional review. As a result, OPOs that make grave errors just keep operating. These errors can render hundreds of organs unusable, leading to a problem of efficiency for OPOs.

CMS performance guidelines

A new CMS rule seeks to address this by reinforcing authority the agency already has to decertify underperforming OPOs.

The rule states that CMS will begin judging an OPO’s performance based on its donation and transplantation rates. Essentially, the more donations and transplantations an OPO coordinates, the better their overall performance score will be. The lowest performing OPOs, according to these new guidelines, will be subject to decertification and replacement.

Ideally, this threat will incentivize underperforming OPOs to make changes ahead of the CMS quadrennial review. But 2021 data reveals that 42 percent of OPOs are already performing so poorly that they would automatically be subject to decertification with these new standards.

Time will tell if the new rule has any teeth. In the meantime, the country could also consider changing how OPOs are paid.

Paying OPOs fairly

Right now, a cost-based reimbursement system funnels Medicare payments to OPOs for “reasonable costs” incurred during procurement and transplantation, like costs for transportation and diagnostic testing. Rather than paying OPOs based on self-reported costs, the country could implement performance-based payment models.

These models could align with the new CMS rule and pay OPOs based on their donation and transplantation rates. However, an increase in volume doesn’t necessarily mean OPOs are actually doing better. To address that issue, CMS could include performance measures beyond volume, such as patient survival rates or the number of organs an OPO discards each year.

Transforming the network and holding OPOs accountable could have a significant impact on racial equity in organ donation. In 2022, over half of all white patients on the transplant list received organs compared to just 30 percent of Black patients on the list. Ensuring that underperforming OPOs improve is a matter of importance for the whole system, but particularly for underserved patients who already face additional challenges accessing lifesaving care.

No matter what tools we use, what’s clear is that we cannot keep rewarding OPOs for low performance. Introducing competition is an important way to encourage improvement, as the 2023 law seeks to do by breaking up the UNOS monopoly. But we can’t stop at competition: We should flex our regulatory muscles, too.

Katherine O’Malley is a policy analyst at BU’s School of Public Health and the Partnered Evidence-Based Policy Resource Center at Veterans Affairs. She can be reached at keomall@bu.edu.

“POV” is an opinion page that provides timely commentaries from students, faculty, and staff on a variety of issues: on-campus, local, state, national, or international. Anyone interested in submitting a piece, which should be about 700 words long, should contact today@bu.edu. BU Today reserves the right to reject or edit submissions. The views expressed are solely those of the author and are not intended to represent the views of Boston University.