Arnold Ventures (AV) is a philanthropic organization focused on advocating for evidence-based policy, including with a focus on health care.
Over the past few years, we have taken a particular interest in organ donation reform, as it presents one of the clearest opportunities to further our dual goals of improving patient outcomes while reducing health care costs. Additionally, and as recently highlighted by Ben Jealous, former President of the NAACP, we believe the OPO Final Rule “is a major win for Black patients and health equity,” as communities of color are deeply disadvantaged by the current system. Indeed, a preponderance of peer-reviewed research has found that, in the absence of OPO accountability, OPOs have systematically deprioritized care for Black patients, as well as other communities of color.
The OPO rule is also a critical step toward delivering care for COVID patients and survivors. As the Washington Post editorial board wrote in August 2020, “Some 33 Americans die every day for lack of transplantable organs to save their lives. Many more wait, crowding into dialysis centers and other health-care offices in the midst of a pandemic. Much of this death and waiting is unnecessary, because the organs would be available if those responsible for collecting and transporting organs did a better job. It is past time the government demanded it of them.”
Our research is centered on inefficiencies in the network of 57 organ procurement organizations (OPOs), the federal monopoly contractors charged with leading organ recovery efforts. Peer-reviewed, AV-supported research from the University of Pennsylvania estimates that glaring OPO failures contribute to as many as 28,000 organs not used for transplant every year. As Sens. Wyden and Grassley recently noted, “OPOs have been severely underperforming for decades.”
The lack of accountability in the system includes a government system that relies on self-interpreted and self-reported performance metrics, which OPOs themselves have admitted are not reliable. As such, AV supports the pro-patient, pro-equity OPO Final Rule CMS finalized in November 2020.
AV-supported research indicates that OPO underperformance is an industry-wide problem, with OPOs, in aggregate, recovering organs from only 35% of potential donors. Despite this persistent underperformance, no OPO has ever lost a government contract, contributing to a culture of complacency. According to the Washington Post editorial board, “In a system in which these OPOs have an effective monopoly on organ recovery within their zones, there are few incentives for them to improve unless decertification is a serious possibility. [HHS] administration should…finalize the rule, as soon as possible.”
Investigative reporting, as well as oversight letters from Reps. Katie Porter and Karen Bass, then Chair of the Congressional Black Caucus, have also highlighted the inadequacy of placing failing OPOs on performance improvement plans, none of which have ever led to OPO improvement. And while OPOs have attempted to fearmonger about the prospect of holding failing OPOs accountable through decertifications, we highlight a statement from the past president of the Association of OPOs, who correctly noted: “There were originally 128 OPOs, and after decades of consolidations there are now  OPOs; never has this process been disruptive. Forcing OPOs to continually earn their contracts is a patient-centric accountability mechanism, ensuring that OPOs operate with the urgency befitting the life-and-death consequences of this work.”
As DJ Patil, the former chief data scientist of the United States under President Obama, wrote in support of the OPO rule in the Journal of the American Medical Association, the most efficacious solution for improving a failing OPOs performance is, in fact, to replace its leadership. AV-supported research led by the Bridgespan Group creates a roadmap for how CMS can do so seamlessly and effectively by replacing failing OPOs with higher performing ones, and while foregrounding health equity through the process.
As the past president of the Association of OPOs also wrote, “HHS’s [Final Rule] signals something potentially game-changing for patients: allowing the highest performing OPOs to replace those who have proven themselves incapable of serving their communities. To the extent that an OPO is not able to rise to the challenge of a high standard, the focus of our attention and energy must be on better serving patients on the national waitlist, not on protecting specific OPOs.”
With 1,000 patients removed from the organ waiting list every month because they have died or become too sick to transplant, we urge CMS to enforce decertifications of poor performing OPOs without delay.
Real accountability for government contractors must begin as soon as possible, and be enforced as strongly as possible, to ensure that patients on the waiting list receive the transplants they deserve.