The life-saving benefits of successful organ transplantation to individual patients are obvious. But is it possible to put a value on the organs and tissues of a deceased donor to society as a whole? Would the supply of deceased donor organs expand if we spent more money to get them? How much should we spend? In this Forum, the Editors of Transplantation present an analysis and discussion of the economic aspects of deceased donor organ that addresses these questions.
John Mendeloff and colleagues at the University of Pittsburgh sought to determine whether deceased donor organ procurement was not only a good health investment but also how much it would be theoretically worth spending to obtain additional organ donors (1). They estimated the lifetime differences in healthcare costs, and the benefits in terms of quality adjusted life years (QALYs) gained resulting from organs transplanted from deceased donors. Using primarily reports from the published literature, the authors estimated for each organ type transplanted the average number of QALYs achieved and the costs they generate. Then, per organ benefits and costs were multiplied by the number of organs from the typical donor and summed to calculate the cost per QALY from obtaining an additional donor. Mendeloff et al. estimate that the typical donor generates about 13 QALYs at a cost of about $16,000 per QALY. They conclude that, making any reasonable set of assumptions, the present cost per QALY of transplants from decreased donors is remarkably inexpensive. The authors emphasize that society could spend much more per donor to increase the donor supply without exceeding an excessive cost of the QALYs resulting from additional transplants.
In an accompanying commentary, Larry Hunsicker notes that the profound shortage of organs for transplantation—essentially a noneconomic factor—clearly limits access to the effective treatment of organ replacement (2). He questions whether this limitation is entirely noneconomic. Hospitals resist increases in payments for deceased organ donors and organ procurement organizations are pressured to reduce costs for organ donation, especially in regard to hospital development and promotion of organ donation. He supports Mendeloff’s conclusion that we spend remarkably little money to obtain deceased organ donors. Hunsicker further emphasizes that although the QALY approach is useful, we need better, more effective criteria to measure outcomes of medical care in all areas of medicine, especially transplantation. He feels that the science of organ donation is really in its infancy and cites the need for various studies to determine which deceased organs could be used safely and effectively. Clearly, it would be cost effective to spend more money to support the science of organ donation. In addition, reimbursement for organ procurement must be protected and expanded. Medicare and Medicaid should continue the policy of treating costs of organ donation as a pass through, rather than cap these costs as a DRG. And all health insurers should be educated in the remarkable cost effectiveness of deceased organ transplantation. Most importantly, Hunsicker urges that we need to increase the collection of appropriate outcome data and determine the best methods of analysis to provide a rational basis for allocation of resources.
Eric Johnson and Daniel Goldstein of the Columbia University Graduate School of Business emphasize that great effort should be made to increase the number of individuals who decide to become organ donors (3). They examine in their article the role of one factor: the no action default for agreement concept. The authors argue that decisions to be a donor (or not) are influenced by the form in which the question is asked. They describe research showing that presumed consent increases agreement to be a donor, and compare countries with opt-in (explicit consent) and opt-out (presumed consent) defaults. Their analysis shows that opt-in countries have much higher rates of apparent agreement with donation, and a statistically significant higher rate of donation, even with appropriate statistical controls. Johnson and Goldstein provide an interesting discussion of the costs and benefits associated with both defaults as well as mandated choice.
1.Mendeloff J, Ko K, Roberts MS, et al. Procuring organ donors as a health investment: how much should we be willing to spend? Transplantation
2004; 78: 1704.
2.Hunsicker LG. The economics of deceased donor transplantation: a microcosm of health care. Transplantation
2004; 78: 1711.
3.Johnson EJ and Goldstein DG. Defaults and donation decisions. Transplantation
2004; 78: 1713.