Transplantation at the Nexus of Behavioral Economics and Health Care Delivery

Abstract

The transplant surgeon's decision to accept and utilize an organ typically is made within a constrained time window, explicitly cognizant of numerous healthrelated risks and under the potential influence of considerable regulatory and institutional pressures. This decision affects the health of two distinct populations, those patients receiving organ transplants and those waiting to receive a transplant; it also influences the physician's life and their institute's productivity. The numerous, at times nonaligned, incentives established by the complex clinical and regulatory environment, have been derived specifically to influence physicians' behaviors, and though well intended, may lead to responses that are nonoptimal when considering the myriad stakeholders being influenced. This may compromise the quality of care provided to the population at risk, and has potential to influence the physicianpatient relationship. A synergistic collaboration between transplant physicians and economists that is focused on this decision environment may help to alleviate these strains. This viewpoint discusses behavioral economic principles and how they might be applied to transplantation. Specifically, the previous medical decision-making literature on transplantation will be reviewed and a discussion on how a behavioral model of physician decision making can be utilized will be explored. To date this approach has not been integrated into transplantation decision making.

Association between Kidney Transplant Center Performance and the Survival Benefit of Transplantation Versus Dialysis

“…Despite the significant differences in patient outcomes between centers, there are concerns about quality oversight and the potential reduction in transplant rates among lowperforming centers (14,15,18,22). Concerns about performance evaluations generally derive from the fact that measures have inherent limitations (e.g., inability to account for disproportionate prevalence of underlying risk factors) that may unintentionally bias reports (22)(23)(24).…”

“…Since publication of the COP, centers with low-rated performance have had significant decline in transplant volume, whereas transplants have continued to increase among other centers (16). Although the specific mechanisms for this association have not been comprehensively evaluated, it is plausible that centers that receive low-performance evaluations have become increasingly risk averse (14,15,18). However, quality oversight may have substantial benefits for identification and improvement efforts for centers with suboptimal outcomes (14,19).…”

“…This trend is particularly notable given that transplant volume had increased in each consecutive year between 1989 and 2006 (13). Although there are likely multiple causes explaining this stagnation, one potential contributing factor relates to increased oversight of transplant centers (14)(15)(16). In 2007, the Centers for Medicare and Medicaid Services (CMS) issued a Conditions of Participation (COP), which explicitly linked performance of transplant centers, as measured by risk-adjusted post-transplant outcomes, with access to reimbursement (17).…”

Association Between Liver Transplant Center Performance Evaluations and Transplant Volume

“…Our findings may also reflect active risk aversion by transplant centers. That is, it is possible that centers with LP evaluations are reluctant to accept donor organs or list patients that are perceived to be higher risk and considered a threat to a center's measured performance (25,26).…”

Balancing Accountable Care With Risk Aversion: Transplantation as a Model

“…The decision to list a patient for transplantation and subsequently accept a deceased donor organ rests at the intersection of many competing priorities. As elegantly described by Schnier et al in this issue of AJT, the transplant physician must weigh patient demographics, donor quality, financial realities and regulatory consequences when offered a potential donor organ (2). Ideally, the decision to accept the organ would focus on the straightforward question, "will this patient benefit from this organ"?…”