Alvin Roth
MARKET DESIGN, KIDNEY, AND
HEALTH INEQUALITY
Festival of Economics 2017
June 1- June 4
Market design, kidney exchange,
and health inequality
Unequal Health
Festival of Economics
Trento, June 1, 2017
Al Roth
Stanford University
2
Markets and marketplaces are ancient human
artifacts, like language
And just as there are many natural languages, there are many kinds of
markets and marketplaces
Not all markets are commodity markets
3
NY Stock Exchange
4
Matching markets
– In many markets, you care who you are dealing with, and prices don’t
do all the work
– (In some matching markets, we don’t even let prices do any of the
work…)
Stanford doesn’t raise tuition until just enough applicants
remain to fill its seats
You can’t just show
up for work at
Google, you have to
be hired…
6
Matching markets are markets in
which you can’t just choose what
you want (even if you can afford
it)—you also have to be chosen
In matching markets, prices don’t do all the work.
In some matching markets, we don’t allow prices to
do any of the work.
Health inequality
• Kidney failure
8
Figure 1.5 Trends in adjusted* ESRD incidence rate (per million/year), by race, in the U.S.
population, 1996-2014
Data Source: Reference Table A.2(2) and special analyses, USRDS ESRD Database. *Adjusted for age and sex. The standard
population was the U.S. population in 2011. Abbreviations: Af Am, African American; ESRD, end-stage renal disease.
.
2016 Annual Data Report, Vol 2, ESRD, Ch 1
9
Patients receiving renal replacement
therapy (dialysis) in 2010 (estimate)
Liyanage T, Ninomiya T, Jha V, et al. Worldwide access to treatment for end-stage
kidney disease: a systematic review. Lancet 2015;385:1975-82.
10
Kidneys Transplanted per million population
U.S.A.
Italy
Mexico
Philippines
Nigeria, Phillippines
(Global Observatory on Donation & Transplantation)
11
In the U.S., 100,000 people are on the
deceased donor waiting list, but we only
have 12,000 deceased donor transplants
per year
Elsewhere, 2-7 million people die every year
worldwide due to inability to pay
for either dialysis or kidney transplantation
The situation is similar in Europe
13
Kidney exchange—U.S. background
• Many more people need kidney transplants than
there are available organs.
• The waiting list in the US has about 100,000 people
– The wait can be years, and thousands die while
waiting
– Recently about 12,000 transplants/year from
deceased donors
• Transplantable organs can also come from living
donors.
– In recent years we’ve had about 6,000
transplants a year from living donors in the U.S.
• Sometimes donors are incompatible with their
intended recipient.
• This opens the possibility of exchange .
14
Simple two-pair kidney exchange
Donor 1
Blood type
A
Donor 2
Blood type
B
Recipient
1
Blood type
B
Recipient
2
Blood type
A
15
Notice that no money changes hands…
• Kidney exchange is an “in kind” exchange
• Section 301,National Organ Transplant Act
(NOTA), 42 U.S.C. 274e 1984: “it shall be
unlawful for any person to knowingly
acquire, receive or otherwise transfer any
human organ for valuable consideration for
use in human transplantation”.
16
Article 21 of the Council of Europe’s (2002)
Additional Protocol to the Convention on Human
Rights and Biomedicine, on Transplantation of
Organs and Tissues of Human Origin:
“The human body and its parts shall
not, as such, give rise to financial gain”
17
2-way exchange involves 4 simultaneous
surgeries
18
18
Chains initiated by non-directed (altruistic)
donors
Non-directed donation before kidney
exchange was introduced
Nondirected
donor
Wait
list
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Chains initiated by non-directed (altruistic)
donors
Non-directed donation before kidney
exchange was introduced
Non-directed donation after kidney
exchange was introduced
Nondirected
donor
Wait
list
Nondirected
donor
R1
D1
R2
D2
Wait
list
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A better picture
Rare 6-Way Transplant Performed
Donors Meet Recipients
March 22, 2007
BOSTON -- A rare six-way surgical
transplant was a success in
Boston.
NewsCenter 5's Heather Unruh
reported Wednesday that three
people donated their kidneys to
three people they did not know.
The transplants happened one
month ago at Massachusetts
General Hospital and Beth Israel
Deaconess.
The donors and the recipients met
Wednesday for the first time.
Why are there only 6 people in this
picture?
Simultaneity congestion: 3 transplants +
3 nephrectomies = 6 operating rooms, 6
surgical teams…
21
Simultaneous cycles and Nonsimultaneous extended altruistic
donor (NEAD) chains
D1
D2
R1
R2
Conventional cycle
NDD
D1
D2
R1
R2
Non-simultaneous chain
Since NEAD chains can be non-simultaneous, they can be long
Roth, Alvin E., Tayfun Sönmez, M. Utku Ünver, Francis L. Delmonico, and Susan L.
Saidman, “Utilizing List Exchange and Undirected Donation through “Chain”
Paired Kidney Donations,” American Journal of Transplantation, 2006
22
23
1
2
3
4
5
6
Transplant Date:
Jul 2007
Recipient's State:
AZ
OH
OH
OH
MD
MD
Recipient's Sex
and ABO type:
O
O
A
A
B
A
O
A
A
B
A
Recipient's PRA:
62%
0%
23%
0%
Recipient's Ethnicity:
Cauc
Cauc
Cauc
Cauc
Donor's Sex
and ABO type:
O
Recipient-to-Donor
Relationship:
1
7
8
9
10
Jul 2007 Sep 2007 Sep 2007 Feb 2008 Feb 2008 Feb 2008 Feb 2008 Mar 2008 Mar 2008
Wife
Daughter Mother
Husband Mother Daughter
Brother
Sister
MD
NC
MD
A
A
A
A
A
AB
A
AB
82%
78%
64%
3%
100%
46%
Cauc
Hispanic
Cauc
Cauc
Cauc
AA
Friend
Friend
Brother
Brother
Mother
Daughter
2
Husband Daughter
Wife
Wife
Father
Husband
OH
3
A
1
The initiating donor was an unpaired altruistic donor from Michigan.
The recipient of Transplant 6 required desensitization to HLA DSA by T and B cell flow cytometry.
3 The recipient of Transplant 9 required desensitization to blood group (AHG titer of 1:8).
2
24
Feb 2012, NKR: a NDD chain of
length 60 (30 transplants)
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KPD and NDD Transplants in U.S.
26
KPD and NDD as % of LD in the United States
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Kidney
exchange
outside
the U.S.
Wednesday, August 3, 2016 First kidney exchange in Nepal
March 7, 2016 First paired kidney exchange transplant done in Singapore
Friday, July 24, 2015 Kidney exchange in Turkey (1st exchanges there)
April 10, 2015 A first non-directed donor kidney exchange chain in Italy
March 30, 2015 A first kidney exchange in Argentina
March 5, 2015 First kidney exchange in Poland
Friday, November 7, 2014 Kidney exchange in Spain: now more than 100 transplants
June 7, 2014 Kidney exchange in France
December 19, 2013 Kidney exchange in Vienna
August 19, 2013 Ten kidney exchange transplants on World Kidney Day in Ahmedabad, India
July 28, 2013 First Kidney Exchange in Portugal:
July 23, 2013 Kidney exchange chain in India
June 6, 2013 Kidney exchange between Jewish and Arab families in Israel
December 26, 2012 Kidney exchange in Canada
December 1, 2012 Kidney exchange in India
June 1, 2012 Mike Rees and Greece: an intercontinental kidney exchange
March 27, 2012 Kidney exchange in Britain
February 5, 2012 Kidney exchange in Australia, 2011
April 29, 2011 First kidney exchange in Spain
December 8, 2010 National kidney exchange in Canada
August 3, 2010 Kidney Exchange in South Korea
Tuesday, August 3, 2010 Kidney Exchange in South Korea
Friday, July 30, 2010 Kidney transplantation advice from the Netherlands
March 9, 2010 Kidney exchange news from Britain (1st 3-way there)
January 27, 2010 The Australian paired Kidney eXchange (AKX) goes live
June 25, 2009 Kidney exchange in Canada (1st exchange there)
February 27, 2009 Kidney Exchange in Australia (in Western Australia)
28
Global kidney exchange: a possibility of mutual aid
United States
Two-way
exchange
Developing World
Transplants
unavailable
29
First global kidney exchange, with a pair
from the Philippines—January 2015,
• Alliance for Paired Donation (Rees et al.)
Nondirected
donor
Jose
Kristine
R2
D2
Jose Mamaril received a kidney from a non-directed American donor in
Georgia. His wife, Kristine, donated one of her kidneys to an American
recipient in Minnesota, whose donor continued the chain by donating to a
patient in Seattle.
…
THE BLADE/JETTA FRASER
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The chain to date
Safely home…
• $50,000 escrow fund for post-surgical care
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Global Kidney Exchange
The GKE proposal is “self-financing”.
• Back of the envelope calculation:
– cost of hemodialysis ≈ $90, 000 per year
– average time under dialysis ≈ 5 years
– cost of transplant ≈ $120, 000 per surgery (plus
$20,000 in maintenance therapy costs per
patient per year)
• But in steady state, waiting time decreases. So
dialysis costs will go down…how long will GKE
remain self financing?
33
GKE remains self financing even when it
becomes widespread.
Intuition:
• Some domestic pairs immediately find a match
• Some other do not find a match upon arrival.
– They increase the average waiting cost
• International pairs get matched to those the
latter type of domestic pairs
• So even if the average dialysis cost is less than
the surgery costs, GKE can still be self-financing
because it matches domestic patients with
higher-than-average dialysis costs.
34
The medical logistics may not be the hard part
35
Financial flows
• Savings on Dialysis
– Medicare—complex legislative/bureaucratic
– Private insurers (33 months)
• New Costs:
– Surgeries—transplant centers
– Post surgical treatment in home countries
– Infrastructure development in home countries
• Self-insuring companies may provide the financial bridge
– They bear the costs of dialysis
– They would be glad to see their employees back at
work
36
Repugnance constraints
• Living donors
–From poor countries
• As a first reaction, many people are going to conflate
global kidney exchange with buying kidneys (which is
illegal everywhere except Iran—a ‘repugnant
transaction’)
37
GKE in the AJT
38
Abstract: Engaging compatible kidney donor–recipient pairs from
other countries for participation in a paired kidney exchange
program in the United States poses a number of ethical challenges
that deserve close scrutiny…
39
• Repugnance Concerns:
– Inadequate post-surgical care
• Escrow funds for immunosuppressive
drugs and post surgical care (in
Philippines)
• Basic infrastructure (in Nigeria)—USAID?
– Inappropriate/illegal/unethical donor
solicitation (how can we ensure that foreign
donors aren’t selling their kidney?)
• Family requirement?
• For non-directed donors too?
40
Repugnance
• 1. “the plan is really not about the international
recipient (nor…about the international donor), but
only about getting organs for US citizens. So it is
exploitative."
• 2. “Lets solve problems at home first…We should
encourage programs that allow Americans to help
Americans."
• 3. “There is an exploitation of a social condition
(being destitute in a foreign country) that kidney
transplantation should not be the remedy of
resolving social inequities."
41
GKE in Mexico: A Bridge of Life
“Just as US President
Donald Trump is
seeking to build a wall
of thousands of miles
on the border with
Mexico, a tireless
surgeon and a
renowned economist
join forces to exchange
organs between citizens
of both countries"
42
The Mexican GKE Chain
43
Information deserts
From Phil Held
44
The economics of giving to each his own
Domani
Cinzia Caporale, Nicola Lacetera, Ignazio Marino, Alvin E. Roth
46