Breaking up the Organ Monopoly
Transcript
0:23
All right.Tyler, what are you obsessed with this week?Devin, this one has been driving me, crazy all week long.So this is a great, great thing to get off my chest and to talk about.Okay, great.So so David, I was recently reading about a report that was talking about the really big problems in the organ donation process, okay?
0:48
And I ran across this article that said that there are are thousands of individuals waiting on the the wait list.And there are also a huge number of individuals who are dying without getting an organ transplant, right?
1:06
So in the order of tens of thousands of people and recently there was a congressional hearing.So this article that I was reading is talking about the Congressional hearings that recently happened.You heard about this?No, I haven't go on, okay.Alright.
1:22
So this article that I was reading is talking about these Congressional hearings and there's going to be some changes to the process, but the article that I was reading was from 1986.Well, okay, so but we've like improved a bunch since then, right?
1:41
No.Yeah.So the It was interesting because this article was talking about this, these hearings that were held up hitting in 19, in the mid-80s about the inequality, and the inefficiencies in the organ allocation system.
1:58
And so, in the United States, there are there's one organization.It's a not-for-profit organization called United Network ordering sharing, What is it like company?I don't know.Hold on a sec.No, no, just the United Network for organ.
2:15
Sharing for organ sharing.Yeah, so it's this organization is nonprofit organization that has an exclusive contract with the United States government to not only run the the matching system but also to be involved in how these organs are being distributed.
2:36
And Dave recently come under some I would say very pointed criticisms, right?So, you know, this is this like, massive, you know, they call it almost like a quasi-governmental agency because it has this exclusive contract.
2:52
It has what some people are now calling a monopoly, right?So it shouldn't be the case that one company has the, the only access to this like huge resource that, you know?And if they were like, really good at running it, maybe we'd look the other way, but apparently, they're not great at running it or, at least.
3:10
There are massive inefficiencies and lots of people who could whose lives could have been saved.If only the program have been run better and that's pretty daunting, right?And so recently there's been some about a year ago.There were some Congressional hearings mostly LED out of seven.
3:29
Senator Warren.From Massachusetts, has been at the Forefront of looking into reforming at least examining shedding some light on the organ.Allocation and transplantation process.
3:45
And recently they just made it.So just in the past week there was a change in the policy or in the process that would allow other organizations.Besides you knows to basically step up and say wait a second, maybe we can run this whole system better than you.
4:05
Nose has been running it which seems like a good idea to me, right?Yeah.Competition being being what drives Innovation.I feel like that's kind of like the American capitalist ideal, right?Yeah.Would it surprise you to learn that you?
4:20
Nose has been the only organization to have this contract with the government to run this?It's a nationwide contract and they've had exclusivity for over 40 years since the process since the system was established.
4:37
It's not surprising.Given what I know about health care but It should be right like we all know that like there's like these three organizations that run all of the electronic Healthcare records.I always think about and I how bad they are and how slow they are to adjust.And like what an absolute pain it is to like change the system in any way.
4:56
Like we just have these massive companies running really important stuff and they're not like hooked up to the latest it.I remember it was it last year.You knows the system went down for like 40 minutes and it just created and absolute chaos.
5:12
So your whole system can't just crash that meant that like people didn't know where the organs were going for 40 minutes and that might not seem like a long time, but that meant that people died who could have received organs And that crash got a lot of media attention, but it's apparently not the first time or the most significant time that this process is system has failed.
5:36
And like you said, it's based upon technology.So it's very technologically, their algorithms on the allocation and how they are being distributed.Even within smaller markets, a small Regional areas, but the technology is so important to so many people particularly people.
5:54
Who are waiting for these organs and the in efficiencies and the failures.In the breakdowns in the system are absolutely mind-boggling.There is one statistic that was shared that it that the organ procurement organizations or you knows which operates our overseas.
6:14
The, the organ procurement organizations that the, it's something like five times more likely to lose or damage a human organ in transit.Then An airline is to lose or damage a piece of luggage.
6:29
Well, that is totally mind-boggling because I feel like I have to buy a new suitcase every time I travel because of the ways that it's handled like, it just like is falling apart by the time I get it on the other end.So if like, airlines are better at this than the people who are in charge and it's not the people's problem, I'm sure.
6:45
But like the sort of system in which, you know, these organs are so fragile and delicate and nobody doesn't understand that.So, is it just that there?Going too far.Is it right?Like how they traveling too far?Like, what is the problem?I think it's so complicated that there isn't one problem that's able to be fixed, right?
7:05
So it's not just a transportation issue, it's not a logistical issue.It's also a question about how we decide we being, you knows how you knows decides who gets, which organ and the organs are all treated differently because there are different processes and different statistics and data and Technologies involved in.
7:30
H-how organs, like for example, and a heart is treated differently than a kidney is treated differently than a set of lungs or a pancreas or something like that.So the way in which its allocated, it's really complicated but also people on the waiting list all have different medical needs.
7:47
They all live in different places.They all live different distances from the transplantation centers.So all of these things and they're and those issues are those characteristics of the patient who Who needs the organ can be constantly changing as well.
8:02
They're not, you know, they could be getting sicker and sicker and sicker, as they're waiting, which most people do.And then they would, if we were allocating the organs based upon who needs it, the most, which is one model of allocating, scarce resources, whoever needs it.
8:22
The most that person as they continue to get sicker would, theoretically, move up the line.And Beast and be higher on the list, right?I mean that seems so tight.It's complicated Ikat is you know, snow minute by minute.So some of the patients that we see are just can crash really quickly and so they move from like definitely needs an organ but not now to needing it right now within the course of maybe an hour.
8:49
And how do you communicate that with a giant organization that then is trying to find those organs?It just seems if what you're doing is basing it on On sickness and not on geography that the Acuity of the illness.Seems really complicated.
9:07
Yeah, it is and it's always changing and it is dependent upon how sick the patient is in all other aspects of their lives, right?So the term we use is comorbidities so if I have if I'm in liver failure, it's not just my liver that's going to be a problem, it's going to be everything that kind of Of stems or falls out of that liver failure.
9:31
Could be my heart.Could be infections.It could be, you know, problems with the wit no delirium.And all these other issues that also complicate the assessment of whether or not.I am the best person to get this.And, you know, if we want to make this even more complicated, or try to unpack it a little bit more the way in which the United States Healthcare System is structured favors.
9:58
Who are the most vulnerable?Oh geez.People who need it?No, so if it's not the most vulnerable at least not really the sickest always write such a really person who needs it.
10:17
The most is it.The people who have the most money I'm afraid it is no, no.And it's not just like an Will being able to go out and purchase a kidney, right?It's not just because there are some really strict rules about compensation, and you can't buy and sell human organs in the United States.
10:39
It's illegal.So, the people who have access to resources in particular, people who have access to massive amount of resources are able to game the system in a way that benefits them to the detriment of everybody else does this sound familiar in any way?
10:57
I mean, Does but I guess, I guess, I don't understand how that works.Tyler, because part of the reasoning behind not being able to buy and sell organs, is that it would disproportionately hurt the poor and it's one way of trying to level the field.So, how is it that rich people are still gaming.
11:15
The system to get organs over people who are poor?So here's one of the most popular examples that people look to to illustrate.This problem is Steve Jobs, so I found her you've heard of him, founder of Apple and he was, I think he had pancreatic cancer, so he was looking for a donation for a, he needed an pancreas donation and what he was able to do.
11:47
So what are the requirements of getting?An organ is you have to live within a certain distance of a transplantation Center and also you have to be listed in that either state or regions list of people who need the organ.
12:04
So you have to get on the wait list.And so what Steve Jobs was able to do and there's that there's some disagreement about whether how factual all of these little points are because a lot of the records are sealed or confidential or people don't really know exactly.
12:19
How it happened, but the story is that he was able to, not only did he have access to a, you know, Gulfstream Jet private jet that could get him anywhere that he needed to go within an hour or two in the United States, but he was able to purchase property and establish legal residency in various States close to transplantation centers.
12:42
So, for example, one of the biggest ones in the midwest is in, in Nashville, like, at Vanderbilt, Example.So, for example, if I'm trying to optimize the opportunities that I have to get an organ is particularly an organ is, is quite scarce and there's a lot of people on the waiting list, if I buy a house next door, to the transplant center outside of Detroit at Henry, Ford and one outside of Nashville near Vanderbilt and one outside of Houston at MD Anderson, these big transplantation Senators, then You know, I can get on multiple lists and up the chances that I'm going to be able to get access to an organ.
13:27
Yeah, way.It's like going out to dinner and everything is really booked and you put your name on the waitlist for a table at five different restaurants.Whichever one comes up first, that's where you decide to go to dinner.Well, in this is really just the, it's not like, you know, the kind of rich and the middle class and the poor.
13:43
This is like the mega Rich because not many people can just buy a home in multiple locations.Transplant centers are at least not many people like right?Right.Yeah.So it's a very small subset of the country that are able to do this but it also trickles down to other issues of access.
14:07
It's particularly access with when Health when finances are the driving force.So for example, if I am somebody who is financially Lee struggling getting access to preventive care and getting access to diagnostic care and taking time off of work to go to all of these appointments and being able to navigate the healthcare system.
14:33
And being able to physically get to my appointments, these are huge burdens for individuals.And at any point if I not diligent, or I miss an appointment or something gets rescheduled, It just throws a wrench into the entire process and and it just slows down the ways in which people can get access to these life-saving.
14:59
And, and often it's not just, this is going to improve your life.It's like you get this organ or you die, right?These, the stakes could not be higher, right?And I haven't done a ton of work with our hospitals on, you know, allocating organs it.
15:18
Something actually I just signed up to do because I'm really curious about this topic but it also seems to me that there's this question of like adherence and are they going to is this individual going to preserve this organ in a responsible way?And so if you're constantly missing appointments because you don't have good transportation that might look on the healthcare end like you're just not adherent to the medical regimen and maybe you're not a person.
15:42
We want to give an organ to because we could give it to somebody who would take care of it better and it would preserve their life longer.So these are other ways.As in which being poor and having Health, disparities trickles down the way to you know being a responsible person that we would want to give an organ to and it shouldn't be that way.
15:58
And hopefully most of our hospitals are thinking about the bigger picture and and helping people to get access to healthcare.But I can see how, you know, being poor and not having access to other kinds of resources, makes you less liable to get an organ to save your life.So those are the issues on the receiving end, right?
16:18
So the people who are wanting to receive an organ, some of the same issues are at play and maybe even more.So at play on the supply side of this, okay?So people of color, or people who are underrepresented in medicine, folks, from those communities are less likely to be organ donors as well because of all of the systemic inequalities and inefficiency.
16:43
These and issues that go into it.So the supply of organs that are most appropriate for people of color, for example, are significantly underrepresented in the supply and that leads to worse outcomes on the other end as well.
17:02
Oh yeah.I remember we, this got brought up when we were talking about the prison issue where prisoners are more likely to be people of color and so wouldn't they be better?Organ, donors.So shouldn't we pay them by reducing their sentences?Alright.So that was the kind of the logic there.So it is true that there's an not enough organs for people of color and that people of color are less likely to donate, and they would be better matches.
17:23
I still contend that the way to solve this isn't to pay prisoners, but it's a broader issue of supply and demand and how we're meeting that.So what's the solution?So, the solution that the government is taking up, is to open up the competition.
17:43
Basically the Contracting process taking away this exclusive Monopoly from you knows who not only has been the primary overseer and organization since the Inception in the early 80s.But they've actually from what the reports that I've read that they've actually never had it a competitive bidding process for these contracts.
18:06
So nobody is never stepped up and been able given the opportunity to say a different organization to say, you know what, we can do it better, here's how we can can do it.And so these these contracts are were going to be these bids.These proposals are going to be accepted over the next several months and the Department of Health and Human Services is going to pick one or maybe several to try to organize this.
18:32
What's scary about that.Number one, I think breaking up the Monopoly at We'll have good.Good outcomes.I am of the belief in general, that competition breeds Innovation, and it's going to improve it in some meaningful way.
18:48
Not all the time there, but this is similar to basically overhauling the Air Traffic Control process in the United States.All at the same time, it's not the case that we can, it's not the case that we can take six months and figure out how to do it.
19:07
Son.Sunset one organization on board.A new organization, they have new ideas, new infrastructure and then they get going.It has to happen.Like you said, a 40-minute delay in the process or a breakdown in the system leads to people's death.And so this is a process that not only it has to be efficient, but it has to be efficient immediately and having worked in big organizations of various Stripes.
19:33
It does not seem like it's a recipe for a smooth transition.Well hopefully they've somebody's thought of that if you and I have thought of it.Somebody else.Somebody else has that.It's true.That's true.Yeah but if they if you know you guys want to call me it's a Biden.
19:50
Ministration wants to call Tyler, and I and ask for some suggestions for willing to give them Yeah, I have some thoughts.Yeah, Joe doesn't joke, all you fairly regularly.I mean, he calls me about all sorts of stuff.We haven't talked about organs, but maybe I'll bring it up in our next conversation.
20:07
But put that on your weekly agenda for the B Administration.So, lots of like you said, lots of smart people are working on this and it's a process.Like the I think the comparison to the air traffic control is is useful in this situation because it's a process.
20:25
And a system.And and a way that Healthcare is delivered that has to work.It's not like we can abandon organ transplantation, and try to figure out a different way or, you know, we have to make this work in in order for people's lives to be saved and lives to be improved.
20:44
So that's what I'm obsessed about this week organ, allocation process, all right?And we'll post a bunch of links to articles about what the proposal is and what the end efficiencies are and why Steve Jobs shouldn't be able to buy multiple homes and get an organ over somebody else.