Study shows 'gaming' in heart transplant system

March 09, 2004

ANN ARBOR, Mich. - When an organ becomes available for transplant, patients who are sicker are given top priority. But a new study by researchers at the University of Michigan Health System and Penn State has found evidence that heart transplant centers often exaggerated the severity of a patient's condition to increase the likelihood of obtaining a transplant organ.

To address this behavior, the United Network for Organ Sharing (UNOS), which governs organ allocation, initiated changes in the system. Since those changes went into effect in 1999, the researchers found, so-called transplant gaming behavior dropped off.

"Although we did not find evidence of gaming after 1999, suggesting that the new policy regulates the system effectively, 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," says the study's lead author, Dennis Scanlon, Ph.D., assistant professor of health policy and administration at Penn State. The paper appears in the March/April issue of Health Affairs.

In 2003, 1,174 heart transplants were performed; 3,517 people are currently on the waiting list for a heart, according to UNOS.

Before the 1999 rule change, patients awaiting heart transplants were listed in one of two categories, with the highest priority given to those expected to live less than six months without a transplant. Generally, patients who required artificial devices to keep their heart working or who were hospitalized in an intensive care unit were automatically classified as Status 1, the highest priority. Their status did not need to be clinically verified and doctors could leave their patients on the Status 1 list as long as they wanted.

In areas with more than one heart transplant center, this left a high possibility that doctors might exaggerate their patients' conditions or even admit patients to an ICU prematurely in order to boost their chances of receiving a transplant.

Transplant centers are divided into 55 regions called organ procurement organ-izations, or OPOs. Since long transportation time could damage a donor heart, when a heart becomes available, UNOS looks to place that organ within the same OPO so it may be transplanted more quickly. Some regions have only one hospital that performs heart transplants, while others distribute organs among as many as nine centers. The study found most OPOs included two or three transplant hospitals.

"Transplant centers are under pressure to get their own patients transplanted. If the patient is on the fence between priority levels, the tendency is to push the patient over the fence to get the transplant to happen," says senior author Peter Ubel, M.D., associate professor of internal medicine at U-M Medical School and director of the U-M Health System's Program for Improving Health Care Decisions.

Using standard tests to measure competition and market share, the researchers examined patient waiting lists from all 55 OPOs from 1995 to 2000. These are the same techniques employed by the Justice Department and Federal Trade Commission in antitrust proceedings.

The researchers found that before the 1999 UNOS rule change, the more inter-hospital competition that existed within an OPO, the more likely patients were to be listed in the sickest category.

In 1999, UNOS tightened the listing rules, to divide patients into three status levels, with the highest priority reserved for patients expected to live only one month. Doctors are required to recertify their patients on this list every seven to 14 days.

After this 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. The researchers theorize that the new rules create a tougher threshold, making it difficult to exaggerate. Further, there is no benefit to bumping a patient to the middle priority level unnecessarily because organs go first to high priority patients who match the donor's tissue type.

When gaming occurs, hospitals may prematurely admit patients to intensive care units to bump them up the waiting list. This leads to added - and unnecessary - medical expenses and procedures, the study authors point out. In addition, when less acutely ill patients are placed higher on the list, available organs might not always go to the sickest patient.

While the researchers in this study looked specifically at gaming of heart transplant patients, they say they same problems exist for other organs. In 2003, the University of Illinois settled a $2.3 million lawsuit alleging it gamed the system to increase liver transplants at its hospital in the late 1990s, although the hospital admitted no wrongdoing. Rules for ranking liver transplant candidates have also changed recently to make gaming more difficult.

"The new heart patient waiting list policies reduce ambiguity and discretion, and appear to be effective regulators. Tightening rules for other organs where competition is intense may also be necessary," Scanlon says.

"Even with these new guidelines for heart transplants, there's still suspicion of gaming," Ubel adds. "It might just be a matter of time before people learn to game the new system. We must continue to monitor the system and remain vigilant."

In addition to Scanlon and Ubel, study authors are Dr. 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; Dr. Evan Loh, assistant vice president of cardiovascular/infectious disease, Wyeth Corp.

University of Michigan Health System

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