Outcome-Based Regulation and Adverse Selection in Lung Transplantation
Andrew Schaefer, Rice University
Tuesday, April 4, 2023
Organ transplantation programs in the United States have seen increased scrutiny of outcomes in the past twenty years. Under regulations by the Organ Procurement Transplantation Network (OPTN) and Centers for Medicare and Medicaid (CMS), the United States has seen a rise in risk-averse patient selection among transplant programs, resulting in decreased transplantation volume for some programs. However, there is debate in the clinical literature over whether this observed response is rational. In this work, we develop a chance-constrained mixed-integer program to model the perspective of a transplant program that seeks to simultaneously maximize transplant volume and control the risk of OPTN/CMS penalization. Using our model, we demonstrate that under realistic conditions, it may be rational for a transplant program to curtail its transplant volume in order to avoid penalization. Moreover, we demonstrate that this incentive does not disappear even if regulators use accurate risk adjustment for high-risk patients. Our findings provide the first rigorous theoretical evidence that OPTN/CMS regulations create incentives for programs to reject certain medically-suitable patients.