The gap between the number of transplants performed and this potential persists in great part due to a system of misaligned policy incentives—key players have competing agendas that are not aligned to maximize the number of organs transplanted. Transplant centers, while dedicated to patient care, adjust their level of risk aversion based on overly strict acceptance criteria and at times decline to use lifesaving organs. Organ procurement organizations (OPOs), which lead procurement of organs from deceased donors, must comply with an evaluation system that does not actually reward pursuing every organ, every time. Donor hospitals lack incentive to do more than the bare minimum of referring potential deaths to OPOs.

Fortunately, sweeping improvement doesn’t require scientific innovation or development of cures; we can address these issues with policy reforms. Though some of these key players and other stakeholders have argued that the system’s complexity prevents improvement, straightforward policy change has great potential for impact. Specifically, we recommend the following changes:

• The Centers for Medicare and Medicaid Services (CMS) should replace the metrics by which OPOs are evaluated, removing “perverse incentives” that discourage organ procurement and establishing a clear view of OPO performance relative to local potential.
• CMS should strengthen oversight of OPOs with smarter regulation, increased transparency and better accountability regarding performance, allowing for external audits of outcomes and referral data and creating more effective tools to address poor performance.
• The Department of Health and Human Services (HHS) should foster innovation and support increased collaboration between OPOs, hospitals, and transplant centers to maximize transplantation. Visionary practitioners also should work together to pilot new approaches.
• Policymakers and practitioners should support efforts to expand transplant centers’ use of all potential organs.