Transplant surgeons allege corruption and mismanagement in organ transplant system

Surprise accusations in congressional committee hearing reveal organ transplant system in turmoil

Critics of the shortcomings of the organizations responsible for organ donation and transplantation launched a surprise attack in a congressional subcommittee hearing this week.

From the Wall Street Journal:

What Happened?

A U.S. House Energy subcommittee was holding a hearing that was ostensibly about the Health Resources and Services Administration’s (HRSA) ongoing updates and modernization to the Organ Procurement and Transplantation Network.

Both the Republican subcommittee chair (Morgan Griffith, Virginia) and Democratic ranking member (Kathy Castor, Florida) took turns criticizing UNOS (United Network for Organ Sharing), which manages the OPTN. So did the Energy and Commerce committee’s bipartisan leadership, calling for “reform,” “transparency,” “accountability” and a “complete overhaul” of organ transplantation systems.

Surprise witnesses then made shocking allegations under oath that employees of organ procurement organizations (OPO) pressured staff to obtain organs from living patients.

Nyckoletta Martin, a former employee of Kentucky Organ Donor Affiliates, sent a letter to the subcommittee alleging that KODA pressured her and other staff to retrieve organs from an awake patient who later left the hospital alive. When one surgeon refused, she said workers were ordered to find a different surgeon who would perform the operation.

“What is clear to me from my time at KODA is that the OPO does not operate in patients’ interests, and regularly engages in unethical activities for the sole purpose of trying to keep its lucrative government contract,” Martin’s letter said.

A liver transplant surgeon and program director at the University of Alabama at Birmingham, Robert Cannon, testified to the committee that he was requested to procure organs from a spontaneously breathing patient, “which would have been murder.”

Greg Segal, head of an advocacy group called Organize seeking reform of the organ procurement process, alleged (without providing evidence) that another OPO had given potential organ donors large doses of fentanyl to hasten their deaths.

Dr. Seth Karp, surgeon-in-chief of Vanderbilt University Medical Center, asserted previous OPTN Boards of Directors were hand-picked by UNOS in a non-transparent process, to maintain UNOS’s control and power over the entire system.

Dr. Karp also claimed that board and committee volunteers managing UNOS/OPTN are “industry insiders” who have inherent conflicts of interest with their institution or professional organizations.

An index to some of the key moments:

33:34 Segal makes multiple allegations without evidence (fraud and euthanasia; kickback schemes between OPOs and their vendors; racialized prioritization of care; bribery to hide wrongdoing). He claims to have extensive documentation for at least some of these claims, and that whistleblowers told him a culture of retribution at OPTN stopped them from speaking out.

39:35 Dr. Cannon: “I’ve had an OPO administrator recommend I proceed with organ procurement despite legitimate concerns that the donor was still alive.”

45:00 Dr. Karp alleges corruption and mismanagement by UNOS and OPTN.

48:45 Dr. Jesse Roach of the National Kidney Foundation states that in 2023, more than 8,500 kidneys were harvested but never transplanted, allegedly due to logistical mismanagement—23 wasted kidneys per day.

54:26 Dr. Cannon reports being in the midst of a liver procurement surgery of a patient who had been declared brain dead when “the anesthetist said they thought the patient breathed. … The staff called their administrator whose recommendation was ‘we think this was just a brainstem reflex; we recommend you proceed.’ Which would have been murder if we had done so, so we closed the patient.”

The Immediate Fallout

The bombshells achieved what might have been one of their intended effects: inflaming and exposing to the public the dysfunction and conflicts among the major organizations controlling organ transplantation in the U.S.

UNOS (United Network for Organ Sharing) has held the sole contract to manage the Organ Procurement and Transplantation Network (OPTN) on behalf of the federal government since the 1980s. UNOS has been criticized for suboptimal management of the increasingly complex system, which critics attribute to its monopoly over organ donation operations.

After investigation by House and Senate committees and passage of a new law in 2023, UNOS was compelled to overhaul its processes, admit multiple new contractors into the system, and submit to new oversight. That transformation is in early stages.

UNOS was not apparently invited to the hearing. (Dr. Richard Formica, the OPTN president, was invited but did not or could not attend.) UNOS hastily put out a defensive statement saying that any illegal behavior by OPOs should be investigated, followed by boilerplate P.R. that organ donation overall is a big success under UNOS.

The Association of Organ Procurement Organizations (AOPO) released a statement that denied the allegations outright—without investigating or acknowledging any potential problem:

[I]t appears that – once again – our lawmakers are being directed away from the truths about our system to instead discuss a litany of false, misleading, and unsupported allegations, featuring an unbalanced panel of witnesses who reinforce the narrative that erodes public trust in the organ transplantation system.

AOPO then seized the opportunity to call attention to what it considers UNOS’s failures in coordinating the transplantation of donated organs:

[S]cant attention is given to the most alarming issue in transplantation today: the crisis of organ nonuse, in which thousands of transplantable organs go to waste every year. … Today, OPOs are recovering enough organs that no one should die on the transplant waitlist. Yet these organs are not being transplanted. This crisis is largely ignored even though solving it is the single fastest way to save the lives of people dying on the waiting list.

In other words: We’re collecting enough organs; UNOS is wasting them. (This statement does not increase public trust in the system, either.)

The next day, UNOS responded in more detail in a formal statement on its website, denying the allegations made during the hearing and deflecting responsibility for logistics failures resulting in wasted organs (“There are many organizations involved in transporting organs”, etc).

Follow The Money

It’s important to consider the financial incentives involved at each step of the organ transplantation process, because (along with politics) these will inevitably shape whatever structure a reformed transplant system takes.

Organ transplantation is a big business, but like most of health care, its financials are largely hidden from public view.

According to a 2020 Milliman report, total expenditures are in the tens of billions of dollars annually, enough to require everyone in the U.S. to pay between $11-16 per month.

Organ procurement generates over $100,000 per major organ (in either costs or revenues, depending on your side of the transaction).

Transplant hospitals generally pay OPOs for each organ they transplant. The hospital performing the surgery then bills a payer (insurance companies or Medicare) hundreds of thousands of dollars for the surgery (e.g., $442,500 for kidney transplant, up to $2.6 million for a combined kidney-heart transplant).

The more money moving around outside of public view, of course, the greater the potential for problems.

Organ procurement organizations in at least five states are under active investigation by the federal government for overbilling fraud, according to The Washington Post. As the probe intensified this year, investigators reportedly visited the offices and homes of 10 chief executives of OPOs. The head of the AOPO advised its membership of the personal visits in a letter to its membership, according to the Post.

The Kentucky attorney general announced that it is considering the allegations made during the congressional hearing. “We will continue reviewing the facts and Ms. Martin’s statement to identify an appropriate response,” their spokesman told the WSJ.

Stay Tuned

UNOS and AOPO have both decried criticism and public allegations of malfeasance as jeopardizing “public trust in the organ donation system.”

But when transplant surgeons from major universities and the National Kidney Foundation are testifying angrily in front of Congress, the year after bipartisan legislation mandating reform passed that gridlocked and dysfunctional Republican-led Congress (and was signed into law by a Democratic president), all amid a multistate federal investigation carrying the threat of criminal charges, the established players of the organ donation system may reasonably face questions about their own stewardship of that trust.

Sensational accusations garner headlines and attention; we will probably not be privy to whatever further investigation reveals. Even if true, these are only symptoms of a more fundamental and obvious problem: the organ transplant system designed forty years ago is no longer adequate and is failing in multiple ways.

As Dr. Karp summed it up in his congressional testimony (at 1:08:54):

“The transplant system has just gotten way too big. There’s not enough expertise [at UNOS] on logistics, there’s not enough expertise on policy, on ethics, and so this small group is trying to manage this enormous system and they’re just overmatched.”

UNOS isn’t in a position to reform itself—it would require expansion, restructuring and a huge increase in funding (primarily from taxpayers, but insurers and hospitals might also face changes to payment rates).

With billions of dollars and massive tranches of power and prestige at stake, the question is: what comes next?