Tuesday, July 28, 2015

Do pricing guiidelines 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.

    Wednesday, July 22, 2015

    Doctor assisted dying: the debate, and the Dutch experience

    Sangram Kadam points me to two different takes in the ongoing debate on doctor-assisted dying, and whether it should be legalized, and if so how common it should become.

    The first is from the Economist:
    The right to die--Doctors should be allowed to help the suffering and terminally ill to die when they choose

    It begins as follows:

    "IT IS easy to forget that adultery was a crime in Spain until 1978; or that in America, where gay marriage is allowed by 37 states and may soon be extended to all others by the Supreme Court, the last anti-sodomy law was struck down only in 2003. Yet, although most Western governments no longer try to dictate how consenting adults have sex, the state still stands in the way of their choices about death. An increasing number of people—and this newspaper—believe that is wrong.

    "The argument is over the right to die with a doctor’s help at the time and in the manner of your own choosing. As yet only a handful of European countries, Colombia and five American states allow some form of doctor-assisted dying. But draft bills, ballot initiatives and court cases are progressing in 20 more states and several other countries (see article). In Canada the Supreme Court recently struck down a ban on helping patients to die; its ruling will take effect next year. In the coming months bills will go before parliaments in Britain and Germany.

    The second article is by Theo Boer, a professor of ethics at the Protestant Theological University at Groningen. He supported the right to die law in the Netherlands, but now is dismayed by the growth in the number of people choosing to end their lives.
    I supported our euthanasia law, but I was terribly wrong: Dutch ethicist

    It begins as follows:

    "In 2001 The Netherlands was the first country in the world to legalize euthanasia and, along with it, assisted suicide. Various safeguards were put in place to show who should qualify and doctors acting in accordance with these safeguards would not be prosecuted. Because each case is unique, five regional review committees were installed to assess every case and to decide whether it complied with the law. For five years after the law became effective, such physician-induced deaths remained level - and even fell in some years. In 2007 I wrote that ‘there doesn’t need to be a slippery slope when it comes to euthanasia. A good euthanasia law, in combination with the euthanasia review procedure, provides the warrants for a stable and relatively low number of euthanasia.’ Most of my colleagues drew the same conclusion.

    "But we were wrong - terribly wrong, in fact. In hindsight, the stabilization in the numbers was just a temporary pause. Beginning in 2008, the numbers of these deaths show an increase of 15% annually, year after year. The annual report of the committees for 2012 recorded 4,188 cases in 2012 (compared with 1,882 in 2002). 2013 saw a continuation of this trend and I expect the 6,000 line to be crossed this year or the next. Euthanasia is on the way to become a ‘default’ mode of dying for cancer patients."