granting them a monopoly on organ procurement within the service area. However, there may be many transplant centers and donor hospitals within a DSA. Transplants are performed at Transplant Centers (hospitals/medical centers) around the country. There are nearly 300 centers across the country although not every center transplants every kind of organ. Each center maintains its own transplant list and makes its own determinations as to who is accepted onto their list. Once a center accepts patients onto its list, the patients are registered in a national, computerized list maintained by UNOS. Transplant centers are required to join the OPTN. healthiest patients who would otherwise go on peritoneal dialysis are the same healthy patients who receive transplants. Therefore, the range of dialysis patients remaining who could go on peritoneal dialysis could be less than 17-34 percent. CEA • Increasing the Number of Kidney Transplants to Treat End Stage Renal Disease 12 As of October 24, 2019, the OPTN (2019a) reported 94,850 candidates currently on the kidney transplant waiting list. 60,052 of these are active candidates, meaning they are eligible to be considered for a transplant. The remainder are temporarily classified as inactive by their transplant center because current medical problems make them unsuitable for transplantation at that time (OPTN 2019b). Inactive candidates can however stay on the list to accumulate waiting time until they are once again active. In the most recent full year, 2018, 38,796 transplant candidates were added to the list (OPTN 2019e). 11 During that same year, 36,478 were removed from the list: 14,714 received a deceased donor transplant, 6,430 received a living donor transplant, 3,959 died, another 4,394 became too sick to transplant, and 451 refused transplant (OPTN 2019d). Barriers to Obtaining More Kidneys In a typical market, imbalances between supply and demand are addressed via prices. When demand for a good exceeds supply, the price of the good increases thereby reducing demand for the good and inducing suppliers to produce more of the good, thereby eliminating the imbalance. The National Organ Transplant Act, potential buyers (i.e., waitlist patients) are forbidden from directly purchasing organs, and potential sellers (i.e., potential living donors) are prohibited from receiving financial compensation for donation, although they can be reimbursed in part for their expenses. Under these constraints, the overall number of transplants is determined by a supply of donated kidneys that is further reduced due to regulatory barriers. For example, while living donors can be reimbursed for some expenses such as travel expenses, the reimbursement is incomplete because many expenses—such as lost wages and child/elder care expenses—are not currently reimbursed. Moreover, not all donors are reimbursed, as The National Living Donor Assistance Center—a main funder for reimbursement—only, until recently, made reimbursements to donors whose income is 300 percent of the FPL or less. Prior to HHS’s recent publication of Organ Procurement Organizations Conditions for Coverage: Revisions to the Outcome Measure Requirements for Organ Procurement Organizations, which addresses some of the following issues, there has been widespread concerns that OPOs are inefficient at obtaining potential deceased donor organs. Part of the problem lies in how the OPOs are evaluated. Historically, OPOs have been evaluated based on two metrics: the donation rate ratio (actual organ donors/eligible deaths) and the organ yield rate (organs transplanted/actual donor). The former is problematic as OPOs self-report eligible deaths, raising issues regarding the fidelity of the reported donation rate ratio and inherent incentives to boost perceived performance. In addition, the eligible death definition excludes many known and potential donors: donors who meet the circulatory definition of death as opposed to brain death, as well as and donors older than 75 years old (SRTR 2019). The second measure, the organ yield rate, is the ratio of observed to expected number of organs transplanted. Since the number of kidneys transplanted per donor was approximately 1.5 in 2017 (Israni et al. 2019), some argue that the yield rate metric discourages OPOs from pursuing single-organ donors (often older donors) thereby leaving potential organs unutilized (Goldberg et al. 2017). Poor utilization of recovered kidneys may also be a problem. The recovered kidney discard rate nearly quadrupled between the 1980s and 2009 as the donor pool expanded to include older people with more 11 Potential transplant recipients can register on more than one waiting list. To get a better sense of the need for organs we utilize the number of new candidates, some of whom may have registered on multiple lists. CEA • Increasing the Number of Kidney Transplants to Treat End Stage Renal Disease 13 co-morbidities. The discard rate then leveled off as rise in donor age and co-morbidities came to a halt. The median donor age rose from 26 to 43 years and between 1994 and 2009 the median Kidney Donor Risk Index (KDRI) rose from 1.1 to 1.3. In addition, between 1999 and 2009, the number of kidneys biopsied to assess their suitability for transplant doubled from 23.1 to 48.9 percent leading to increased discards