New Policy Curbs Exaggeration of Heart Transplant Urgency

Prior to a policy change in 1999, heart transplant centers were said to be increasingly exaggerating the severity of their patients’ illnesses to increase the odds of their receiving donor hearts.

However, according to a report in the March/April issue of Health Affairs, this “gaming behavior” appeared to stop when the United Network for Organ Sharing (UNOS) narrowed the criteria for listing patients in the sickest category and required verification of patient status.

“There is a lot at stake in this system,” senior author Dr. Peter A. Ubel said in an interview, “and a huge problem with supply and demand.”

“Physicians want to help their patients, and careers and a lot of money are on the line. If they sense that the guy down the street is exaggerating how sick their patients are, or is playing loose with the rules, they may figure they have to do the same in order to level the playing field.”

Before 1999, the highest priority patients (status 1) were broadly defined as those requiring mechanical circulatory support or hospitalization in an intensive care unit, with no restriction on status duration. Other candidates were listed as status 2.

The problem with that system, note the authors, is that physicians may have felt pressured to prematurely admit patients to ICUs and to perform unnecessary medical interventions.

In 1999, UNOS tightened its policy, requiring that highest priority patients be defined as those with an expected life expectancy of less than one month (status 1A), remaining candidates were stratified as 1B or 2. Physicians are now required to verify qualification of 1A status every 7 or 14 days.

To empirically evaluate gaming of the transplant listing system, Dr. Ubel’s team compared waiting list data according to institution competition and market share between 1995 and 2000.

Prior to the UNOS rule change, in organizations with the most inter-hospital competition, patients were significantly more likely to be listed in the sickest category. The relationship remained significant after adjusting for blood type, age, gender, and transplant turnover.

However, since 1999, the discrepancies have vanished and the proportion of patients listed as status 1A, 1B or 2 was similar in transplant centers of varying competitiveness.

Pressure to manipulate the system may continue to increase, Dr. Ubel noted, making it important to monitor the system and close other loopholes that make gaming possible.

“There is a need,” he and his colleagues conclude, “to remain vigilant to the possibility that gaming will return.”

Health Affairs 2004;23:191-198.