Wednesday, July 29, 2015

The grey market for fetal tissue (it can't be sold for a profit, but profits can be made on processing)

There has been recent attention to fetal stem cells, which are used in research into a number of diseases.
The NY Times has the story:
Fetal Tissue From Abortions for Research Is Traded in a Gray Zone

"Videos released by an anti-abortion group during the last two weeks have drawn attention to a little-known practice: the buying, selling and research use of fetal tissue acquired from abortion clinics.

"The group behind the tapes accuses Planned Parenthood of selling fetal tissue for profit — which is illegal and which Planned Parenthood denies doing. House Republicans plan to investigate. This may be just one more battle in the nation’s long war over abortion, but the dispute has raised questions about who the buyers and sellers are, what fetal tissue is used for and what the law allows.
"Companies that obtain the tissue from clinics and sell it to laboratories exist in a gray zone, legally. Federal law says they cannot profit from the tissue itself, but the law does not specify how much they can charge for processing and shipping.

"The National Institutes of Health spent $76 million on research using fetal tissue in 2014 with grants to more than 50 universities, including Columbia, Harvard, the Massachusetts Institute of Technology, Stanford, Yale and the University of California in Berkeley, Irvine, Los Angeles, San Diego and San Francisco. It expects to spend the same amount in 2015 and 2016.
"Fetal tissue can be used only with the consent of the woman having an abortion. Some researchers receive the tissue from abortion clinics at their own institutions, or from tissue banks maintained by some universities. Many buy the tissue from companies that act as middlemen. Those companies pay small fees, usually $100 or less a specimen, to abortion providers like Planned Parenthood, who say they charge only what they need to cover their expenses. The companies then process the tissue and sell it to researchers for higher prices that reflect the processing.

"The fees, which can run to thousands of dollars for a tiny vial of cells, do not break the law, according to Arthur Caplan, the director of the division of medical ethics at NYU Langone Medical Center.

“It appears to be legal, no matter how much you charge,” Dr. Caplan said, adding that there appears to be little or no oversight of the processing fees. “It’s a very gray and musty area as to what you can charge.”

"Many researchers buy tissue from two small California companies. StemExpress, a five-year-old business based in Placerville, Calif., describes itself as “the largest provider of maternal blood and fetal tissue globally.” It also says it offers “special discounts to the academic community.”
"George J. Annas, a law professor and bioethicist at Boston University, said, “What’s going on now is probably legal, but Congress won’t like it.”

"Regarding the companies, Mr. Annas said: “They won’t be real happy that this is all out in the public. This threatens their business. Even if what they’re doing is legal, the law can easily be changed.”

Tuesday, July 28, 2015

Do pricing guidelines for human eggs violate antitrust laws?

The WSJ has the story:
Putting a Price on a Human Egg
Lawsuit claims price guidelines used by fertility clinics artificially suppress the amount women can get for their eggs

"How much is a human egg worth? The question is at the heart of a federal lawsuit brought by two women who provided eggs to couples struggling with infertility.

The women claim the price guidelines adopted by fertility clinics nationwide have artificially suppressed the amount they can get for their eggs, in violation of federal antitrust laws.

The industry groups behind the price guidance—which discourages payments above $10,000 per egg-donation cycle—say caps are needed to prevent coercion and exploitation in the egg-donation process.

But the plaintiffs say the guidelines amount to an illegal conspiracy to set prices in violation of antitrust laws. The conspiracy, they argue in court papers, has deprived women nationwide a free market in which to sell their eggs, and enabled fertility clinics to “reap anticompetitive profits for themselves.”

“It’s naked, illegal price-fixing,” said Michael McLellan, a lawyer for the women.
"Other egg donors say a robust market depends on compensation. “I helped couples achieve their dreams, and in return they helped me go to law school, buy an apartment, pursue my dreams when I was in my 20s,” said Gina-Marie Madow, a four-time egg donor now working as a lawyer at Circle Egg Donation, a Boston-based egg-donation agency. Ms. Madow said $10,000 “feels like the right amount for women to get” for a cycle but didn’t understand the reason behind the price cap. “I just don’t think the [organizations have] done a good job explaining why it exists,” she said.

The price caps might also guard against worries that women might pay more for eggs from mothers of certain ethnic or racial backgrounds, or with such traits as physical beauty or high intelligence. Such a market exists, largely through a small number of agencies that cater to couples willing to pay a premium.

“It’s a concern about eugenics, that women will pay more for eggs from an Ivy League grad,” said John Robertson, a professor of law and bioethics at the University of Texas.

Kimberly Krawiec, a law professor at Duke University who has studied the egg-donor industry, played down such concerns, adding that mothers-to-be generally aren’t looking to build a genetically superior child. Ms. Krawiec said she had little issue with couples paying more for eggs from women with, say, high SAT scores. “Fertile people have been screening for beauty and intelligence for years and years,” she said. “It’s called dating.”

Monday, July 27, 2015

Roger Doooley interviews me about Who Gets What and Why

Ep #68: Disrupting Markets with Nobel Winner Al Roth

My guest today on The Brainfluence Podcast is quite a unique scholar. Al Roth is the Craig and Susan McCaw Professor of Economics at Stanford University, as well as the Gund Professor of Economics and Business Administration Emeritus at Harvard University. He is the author ofWho Gets What And Why: The New Economics of Matchmaking and Market Design. He also happens to have been awarded the Nobel Prize for Economics in 2012.
While winning a Nobel Prize makes Al unique, what sets him apart is his application of his knowledge of economics in solving seemingly intractable real-world problems. His insights have resulted in market creation in areas like city-wide school admissions, hospital internship negotiations, and kidney transplants that save thousands of lives each year.
Today, we’re going to hear how an economics professor turned into a lifesaver and how you can apply some of Al’s insights to your business ventures. The principles that Al has brought to the medical field, and that have been used in some of the great entrepreneurial successes in recent history, are readily accessible to you. These same principles can be used to understand and identify novel business opportunities, reshape the way you view your business and help you experience incredible success.
If you enjoy the show, please drop by iTunes and leave a review while you are still feeling the love! Reviews help others discover this podcast, and I greatly appreciate them!

Listen in:

Sunday, July 26, 2015

Ben Hippen on the economics of transplantation and dialysis

Dr Hippen replies to an earlier article suggesting that incremental changes in current transplant practice could remove the need to radically increase the supply of kidneys, e.g. through financial incentives...

Debating Organ Procurement Policy Without Illusions

Benjamin Hippen, MD American Journal of Kidney Diseases

"For poor patients, the primary payor for dialysis is Medicare, Medicaid, or some hybrid, unless they are ineligible for these programs. The profit margins of dialysis facilities with an average payor mix of Medicare, Medicaid, and commercial insurance is 3% to 4%.12 Crucially, a facility composed entirely of patients with Medicare and/or Medicaid as the primary payor is financially unsustainable because payments to facilities on a per-treatment basis are, depending on local labor and other overhead costs to the facility, frequently less than the cost to the facility to provide the treatment. Although a dialysis facility requires a minimum number of patients to cover labor and operational overhead costs, the total net margin of a typical facility is achieved through cross-subsidization from collections from commercially insured patients."

"A staple of opponents of financial incentives is that incentive proposals would not even bear consideration if transplantation professionals would just stop wasting perfectly good kidneys. Citing a 19% rate of organ discard in the United States, the authors argue that if only we biopsied more kidneys before turndown, made more use of organs with a Kidney Donor Profile Index > 85% (previously known as expanded criteria donors), and increased use rates of organ donation after circulatory death just like many European centers, we would be a long way toward solving the problem.

These arguments betray a lack of understanding of the extant regulatory burdens and financial constraints on US transplantation centers. In the United States, the expected risk-adjusted rate of death-uncensored transplant survival for a deceased donor kidney at 1 year is 96% (14; Fig 6.2), and 1-year expected patient survival is 98% to 99%. These outcomes represent the expectations of transplantation centers by CMS regulators, and failure to achieve these outcomes invites intense regulatory scrutiny under threat of involuntary closure.15 In the last several years, nearly 100 transplantation programs in the United States have gone through expensive stressful “mitigating factors” applications with CMS to avoid involuntary closure because of reported outcomes that were below risk-adjusted expected outcomes, although the data and veracity of the methodology used to calculate risk adjustment has been heavily criticized.16 With some frequency, scrutinized centers are required to enter into a Systems Improvement Agreement, essentially a contract with CMS to put oversight of the transplantation program into a multiyear third-party receivership, at extravagant expense to the transplantation center, until reported outcomes improve.

Regulatory scrutiny of programs that fall below expected outcomes is typically accompanied by denial of Center of Excellence status by CMS. Loss of this designation often causes commercial insurers to cancel insurance contracts and direct referrals to other programs. This is a profound incentive to embrace risk aversion.16 and 17 Refashioning insurance agreements and changing ingrained referral patterns is a slow process and can pose significant medium-term challenges to the financial stability of a transplantation program long after the quality issues have been resolved to a regulator’s satisfaction."

Saturday, July 25, 2015

Nash equilibrium: something on which economists agree

The IGM Forum asks a panel of economists whether they agree or disagree with a given statement. The following statement drew a lot of agreement:

Nash Equilibrium

"Behavior in many complex and seemingly intractable strategic settings can be understood more clearly by working out what each party in the game will choose to do if they realize that the other parties will be solving the same problem. This insight has helped us understand behavior as diverse as military conflicts, price setting by competing firms and penalty kicking in soccer."

Friday, July 24, 2015

Kidney exchange in Turkey, and the state of Turkish transplantation

Here are two articles from the June issue of Transplantation Proceedings

First International Paired Exchange Kidney Transplantations of Turkey    

  • M. Tuncer
  • , S. Tekin
  • , Y. Yuksel
  • , L. Yücetin
  • , L. Dosemeci
  • , A. Sengul
  •  and A. Demirbaş
  • Transplantation Proceedings, 2015-06-01, Volume 47, Issue 5, Pages 1294-1295, Copyright © 2015 Elsevier Inc.



    We estimated that many patients on the waiting list for kidney transplantation in Turkey have immunologicaly incompatible suitable living donors. Paired exchange kidney transplantation (PETx) is superior to desensitization for patients with incompatible donors. Recently we decided to begin an international PETx program.


    We report three international living related paired kidney transplantations which occurred between May 14,2013, and March 7, 2014. The international donor and recipient operations were performed at Medical Park Hospital, Antalya, Turkey. All pairs were living related and written proofs were obtained according to Turkish laws. As with the donor procedures, the transplantation procedures were performed at the same time.


    The uniqueness of these transplantations was that they are the first international exchange kidney transplantations between Turkey and Kirghizia. Currently all recipients are alive with wel-functioning grafts.


    In our institute, a 5% increase was obtained in living-related kidney transplantations by the help of PETx on a national basis. We believe that international PETx may also have the potential to expand the donor pool.

    State of Turkish Transplantation    

    • Sukru H. Emre Prof.
    •  and Ulug Eldegez Prof.
    Transplantation Proceedings, 2015-06-01, Volume 47, Issue 5, Pages 1243-1243, Copyright © 2015 Elsevier Inc.
    The 10th Congress of the Turkish Transplantation Centers Coordination Association (TTCCA) was held on October 15–18, 2014 in the ancient city of Bodrum, Turkey (formerly Halicarnassus), where one of the Seven Wonders of the Ancient World, “Mausoleum at Halicarnassus,” resides.
    This congress also marked the 20th anniversary of the TTCCA. Since its inaugural meeting, TTCCA's congresses have hosted international leaders in the fields of transplantation in transplant immunology, hepatology, nephrology, surgery, radiology, infectious disease, intensive care, nursing, and other related disciplines. Throughout the years, these congresses have served as a great training ground for young Turkish physicians, surgeons, and scientists to meet with world experts and discuss cases. These congresses have also helped Turkish physicians develop international networks so that they may visit transplant centers around the world.
    Twenty years ago, TTCCA was established by two pioneers of Turkish transplant surgery: Professors Tuncer Karpuzoglu and Ulug Eldegez. These men were the ones who approached the young transplant surgeons, physicians, immunologists, and nurses to welcome them, encourage them, guide them and point them in the right direction. TTCCA has had bi-annual national meetings since its inception. These meetings have brought almost all transplantation centers in Turkey together under the TTCCA and initiated a nationwide deceased organ distribution system for kidney, liver, and heart transplantations. This effort was sponsored by a grant provided by Novartis. This was the first attempt in Turkey to institute the equal, fair sharing of organs procurred from deceased organ donors. After almost 10 years of serving in this capacity, TTCCA partnered with the Ministry of Health of Turkey (MoH) to achieve the current organ allocation system. During the development of the new organization under the auspices of the MoH, TTCCA leadership and many members have played crucial roles by serving on many committees of this national organization.
    As a result of these efforts ignited by TTCCA, solid organ transplantation in Turkey has became a routine procedure with reasonably good outcomes.
    Despite these achievements, there are many areas that the transplantation society and MoH can work on:
    • 1. 
      Based on the 2014 statistics, approximately 80% of kidney and liver transplants were done with living donors and only 20% of organs were from deceased donors. In living donor liver transplantation, Turkey is the one of the leading countries in the world together with South Korea. These ratios are the opposite to the ratios of Europe and the US where most of donations are from deceased donors. Therefore, there is an ample opportunity to increase deceased organ donation in Turkey. This effort requires continuous education of the public on organ donation.
    • 2. 
      It is imperative to establish a Turkish Transplantation Network similar to UNOS. Besides what has been achieved, this organization should be in charge of increasing the number of deceased donors, more detailed organ specific data from transplant centers, auditing, controlling the quality of transplant centers in terms of policies, processes, quality and accreditation of medical and surgical staff involved in transplant centers, education, and monitoring transplant related disease transmission.
    TTCCA and MoH have been working with The Transplantation Society (TTS), World Health Organization (WHO), EuroTrans and the Declaration of Istanbul on Organ Trafficking and Transplantation Tourism leadership to honor the concept of the “gift of life,” prevent organ trafficking and increase the number of deceased donors for transplantation. I hope that these commendable efforts would be honored by TTS by allowing the 2020 World Congress to be held in Istanbul, Turkey.
    It has been my pleasure to live through these amazing improvements in Turkish Transplantation along the last 20 years.

    Thursday, July 23, 2015

    Inquiring Minds podcast on Who Gets What and Why

    Here's a podcast about my new book--first quarter hour is devoted to chat between the hosts, and then an interview with me, which starts at 17:30 and goes through minute 53. The whole thing is an hour.