A scary homophobia headline and story: repugnance is alive and well in California

It's not just anti-semites who speak of extermination (see David Brooks on that), anti-gays do too: here's a story just out in the NY Times. California Seeks to Head Off Initiative to Execute Gays

"The California attorney general, Kamala D. Harris, moved Wednesday to block a proposed voter initiative that would mandate the execution of sexually active gay men and women, calling it “patently unconstitutional” and a threat to public safety.

Ms. Harris said she would ask the state Superior Court in Sacramento to relieve her of having to write the title and summary for the Sodomite Suppression Act, which would clear the way for the author, Matthew G. McLaughlin, a lawyer in Huntington Beach, to begin gathering signatures to get it on the ballot.

The highly unusual announcement by Ms. Harris — by all appearances, California law gives no discretion to the attorney general in handling these kind of initiatives — comes as gay groups and others have called on her to block the measure. Ms. Harris, who was just elected to a second term, announced earlier this year that she would run for the Senate in 2016.

In her statement, Ms. Harris signaled her lack of legal options as she threw the ball to the courts. “If the court does not grant this relief,” she said, “my office will be forced to issue a title and summary for a proposal that seeks to legalize discrimination and vigilantism.”

Even if she is forced to proceed, Mr. McLaughlin — who did not return a telephone call seeking comment Wednesday — has a tough road ahead. He would have to gather the signatures of 365,880 registered voters, and it seems highly unlikely that if he succeeded at that, voters in the state would approve a measure like this."

School choice and medical residency matching in Forbes

I was in New York City yesterday for an IIPSC-organized conference on school choice, and it was a nice coincidence to see that Forbes had an article on school choice and other matching processes, that mentions IIPSC.

Prerna Sinha writes about deferred acceptance algorithms, in the medical match and in NYC high school choice: Quantifying Harmony: The Matchmaking Algorithm That Pairs Residents With Hospitals, Students With Schools

"In 2003 Professor Roth (Stanford), who has played a major role in the dissemination of the deferred acceptance algorithm, worked with Atila Abdulkadiroglu (Duke) and Parag Pathak (M.I.T.) to replace the broken high school match system that was previously in place in New York City.Roth realized similar to a stable marriage or residency-student match, a high school-student match would work if individuals and schools were permitted to select alternative options after their most preferred options were rejected.

He is confident that the deferred acceptance algorithm provides a significant improvement over the system that was previously in place, but he believes the school choice system could work better. He clarified, “... there is a problem with how to disseminate information to families about schools.” He also suggested that there would be less congestion and it would be a more efficient process if all charter schools and private schools participated too.
...
 Roth continues to work closely with Neil Dorosin, who was the director of high-school admissions in New York City at the time of the redesign. Dorosin is now the Executive Director of Institute of Innovation in Public School Choice (IIPSC), and Roth sits on the advisory board. IIPSC is a team of specialists in the design and implementation of enrollment and school choice systems. The organization helps communities integrate the latest market design research and technology to solve school choice problems.

Roth calls Dorosin the “Johnny Appleseed” of getting systems like the one in NYC into New Orleans, Denver, and Washington.

Dorosin told FORBES, “Public school choice, this two sided matching market where there are two interested parties (schools and students), exists all over the country, in every big city and most small cities too. In most cases the systems that are set up to organize that two sided matching market, unintentionally, are failing. Failing the kids and the families that are supposed to use them, failing the systems of schools that are supposed to be administering them.”

Private dealings between parents and schools, limited resources and information for some parties, and congestion caused by lack of centralized communication are examples of market malfunctions that lead to disorganized systems.

According to Dorosin, the market design approach (deferred acceptance) addresses the central problem of matching students with schools: high school seats are a scarce resource that needs to be allocated efficiently and transparently in a manner that allows students and parents to feel safe when participating.

Parents and students need to feel safe in listing their preferential choice of schools, free of fear that ranking School A as a top choice will hurt their chances of getting into School B, their second choice. Efficiency involves getting optimal results on the first try and avoiding numerous offers or back and forth between parties. Transparency would allow lottery numbers, school information, and reports about outcomes to be easily accessible by all in a centralized location.

Dorosin says, “These are the elements that lead to a better system. We call this universal enrollment.”

The deferred acceptance algorithm, which is the basis of Dorosin’s universal enrollment concept, has a proven track record with the students of New York City and medical residents across the country. It may yet have applications beyond those it has now. At the very least, you can expect urban districts around the country and possibly around the world to continue to adopt some of the principles."

A non-repugnant transaction that reads like a riddle, reflecting cultural changes

When I was in elementary school (yes, there were schools then), I more than once heard the following riddle, which was a sign of the times:
"a father and his son are in a car crash that kills the dad. The son is rushed to the hospital; just as he’s about to go under the knife, the surgeon says, “I can’t operate—that boy is my son!” How could this be?"

I thought of this riddle (and the role that conventional assumptions about gender roles play in it) when I saw this recent headline in the Telegraph:
Mary Portas: My brother is the 'father' of my son

The story answers the riddle in a way that indicates how much times have changed once again.

"Mary Portas has disclosed how her own brother helped her become a mother for the third time, after becoming a donor for an IVF procedure.

Portas, nicknamed the "Queen of Shops", has told how her wife Melanie Rickey became pregnant with their son thanks to help from her younger brother Lawrence."

The new economics of matching and market design, at Haverford

I'll be giving the Comanor Lecture at Haverford College today.

Here's the announcement:

The Economist as Engineer: The New Economics of Matching and Market Design, a talk by Nobel Laureate Al Roth, Professor of Economics at Stanford University, Monday, March 23rd, 2015 ~ 5:30pm, Sharpless Auditorium

The market for breast milk

Should breast milk be bought and sold?

Andrew Pollack in the NY Times has the story:
Breast Milk Becomes a Commodity, With Mothers Caught Up in Debate

"Breast milk, that most ancient and fundamental of nourishments, is becoming an industrial commodity, and one of the newest frontiers of the biotechnology industry — even as concerns abound over this fast-growing business. The company that owns the factory, Prolacta Bioscience, has received $46 million in investments from life science venture capitalists.
...
"But the commercialization of breast milk makes many people uneasy. They worry that companies might capture most of the excess breast milk and make products that would be too costly for many babies, while leaving less milk available for nonprofit milk banks.

“The competition comes in the form of how much surplus breast milk is there in the country and who’s getting it,” said Kim Updegrove, executive director of the nonprofit Mothers’ Milk Bank at Austin. “The nonprofit milk banks have a long history of providing milk to the sickest babies, and provide it based on medical need and not on insurance reimbursement or financial resources.”

Debate is also intense over whether women should be paid for their milk or donate it altruistically. Opponents of payments, worried about breast milk “farming,” say women might try to increase their milk output unsafely, hide health problems that could make the milk unsafe, mix in cow milk to increase volume or deprive their own babies so they can sell more."

Here are my earlier posts on breast milk.

Organ donation in Mexico: new campaign by the Carlos Slim Foundation

The Carlos Slim Foundation backs organ donation

"MEXICO CITY – Mexico isn’t living up to its potential when it comes to life-saving organ transplants that thousands of Mexicans need in order to continue living, said the Carlos Slim Foundation.

The foundation launched the 2015 “Héroes por la Vida” (Heroes for Life) campaign last month in a bid to encourage more Mexicans to talk with their families about donating their organs in the unfortunate event of their death.

“Today in Mexico, 19,000 people are waiting for an organ transplant,” Vanessa Slim de Hajj said at the campaign launch. “This number is growing every day, and the number of donors in our country is only 3.6 people for every 1,000.”

...
To put things into perspective, consider that in Spain, an international leader in transplants from cadavers, 36 of every 1,000 people are organ do- nors, 10 times the rate in Mexico. The national rate of postmortem trans- plants is less than many other Latin American countries as well.

“This campaign calls on Mexicans to be everyday heroes,” Slim said. “Today we can make a simple decision to save lives.”

...
On the campaign website (www.heroesporlavida.org), volunteers can find information about how to register as a donor and order a donor card. However, the volunteer card isn’t a legally binding document and the ultimate decision falls to family as to whether their loved-one’s organs will be used to save lives.
***************

and here: Campaña de donación: Héroes por la vida

***********
Here's some background: the Slim family has personal experience with kidney transplantation: Slims’ Transplant Inspires Push for Organ Donations

Match Day 2015! 1,035 couples participated...

Congratulations to all the new docs!  Today was Match Day for the National Resident Matching Program (NRMP)

Here's a selection of stories that crossed my screen today:

Press Release: 2015 Residency Match Largest On Record With More Than 41,000 Applicants Vying For Over 30,000 Residency Positions In 4,756 Programs
" An all-time high of 1,035 couples participated in the Match, 110 more than last year, with a 94.8 percent match rate."

The fates of thousands of med school students are decided by this Nobel Prize winning algorithm

Match Day: Then & now

Matching Dreams: Students ring in the future of medicine on the first day of spring (Harvard)

Medical students open envelopes and glimpse their futures: A national event that places graduating medical students into residencies, Match Day is both a celebration and a nerve-wracking affair. (Stanford)

The residency match in Otolaryngology

A recent paper looks at the resident match in Otolarygology, in the context of the overall resident match.

State of Otolaryngology Match: Has Competition Increased since the ‘‘Early’’
Match?  by Cristina Cabrera-Muffly, Jeanelle Sheeder, and Mona Abaza, in the journal Otolaryngology--Head Neck Surgert 2015 Feb 24

"Over the past 60 years, the United States residency match process and characteristics of medical students applying to the match have changed considerably. Centralized matching of postgraduate training positions was successfully implemented nationwide in 1952.1 At that time, just over 10,000 positions were offered through the match. In the 2013 match cycle, there were almost 50 different specialties that offer PGY-1 positions through the National Residency Matching Program (NRMP) match and a total of 26,392 positions offered.2

In 2006, in response to concerns about physician shortages, the Association of American Medical Colleges (AAMC) recommended an increase in the number of medical student postions.3 There was an overwhelming response among allopathic programs in both new schools (13 have matriculated their first class since 2006) and larger class sizes in established schools, with rosters expanding 15% to 18%.3,4 Meanwhile, osteopathic medical schools have doubled in number from 15 to 30 over the past 20 years.3 Therefore, the overall number of graduating medical students has increased considerably, reaching an all-time high in 2013.5 This has a direct effect on the quantity of medical students seeking any residency position, including otolaryngology.

The otolaryngology match has also undergone several iterations since its beginnings. In late 1977, otolaryngology and ophthalmology specialties officially separated.6 In 2006, the otolaryngology match transitioned from coordination by the San Francisco match (SF match) to become part of the NRMP. This transition altered the timeline of the application process in otolaryngology and potentially affected the applicant pool. Prior to 2006, the interview season for early match was generally from October to December, with the rank list submission deadline in early January. Match notification occurred in mid-January.7 This allowed applicants who did not match to complete a separate application for other specialties, although interview periods often overlapped. Once the NRMP began coordinating the otolaryngology match in 2006, the interview season was delayed to November through January, with the rank list submission deadline at the end of February. Match notification now occurs in mid-March.8

The change from the SF match to the NRMP match occurred as the required general surgery intern year became integrated with otolaryngology residencies, eliminating the need to separately interview for a preliminary general surgery position.9 Since 2006, otolaryngology programs have an integrated intern year, eliminating the need for a separate match. The early timing of the otolaryngology match allowed for applicants who did not match into otolaryngology to apply for a different specialty during the regular match of the same year through the NRMP. Applicants participating in the couples match during the early match likely found it more difficult to coordinate match cities when one partner applied to otolaryngology and the other to a regular match specialty. It is unclear whether the competitive nature or the couples match situation was considered when the match timing was changed.

...

"Over the past 16 years, we have seen an increase in the number of US seniors applying to residency. Fortunately, during the same time period, the number of first-year residency positions in all NRMP specialties increased as well. This rate of growth of residency positions appears to be consistent with the recommendation by the Council on Graduate Medical Education, who recommended increasing the number of first-year residents to 27,000 per year by 2015.4 In the same time frame, the number of unfilled NRMP residency positions has decreased by 55.8%. These positions are being filled by non–US seniors since the overall rate of applications and matches increased while the rate of US senior applications and matches stayed constant. Non–US seniors include prior US medical school graduates and IMG. IMG includes both US citizens attending medical school outside the United States and citizens of other countries attending international medical schools. Data suggest that the IMG portion of this group is filling the additional residency positions. In 2002, 18.6% of all NRMP positions were filled by IMG, while in 2013, IMG matched into 24.8% of NRMP positions. Meanwhile, the percentage of NRMP positions filled by prior US graduates has remained stable (between 2% and 3%). The decrease in percentage of unfilled positions is also due to increased IMG matching.

...

"The advantages of the otolaryngology conventional match are the elimination of one of the interview processes (since the preliminary general surgery intern year is now included), as well as improved ability for couples to match together."

Who Gets What--and Why. My forthcoming book now has a website

The June 2 publication date is coming. Here's the publisher's website for my book: Who Gets What--and Why. (The new economics of matchmaking and market design)

Contents
Part I . Markets Are Everywhere
1. Introduction: Every Market Tells a Story 3
2. Markets for Breakfast and Through the Day 15
3. Lifesaving Exchanges 29
Part II . Thwarted Desires: How Marketplaces Fail
4. Too Soon 57
5. Too Fast: The Greed for Speed 81
6. Congestion: Why Thicker Needs to Be Quicker 101
7. Too Risky: Trust, Safety, and Simplicity 113
Part III . Design Inventions to Make Markets Smarter, Thicker, and Faster
8. The Match: Strong Medicine for New Doctors 133
9. Back to School 153
10. Signaling 169
Part IV . Forbidden Markets and Free Markets
11. Repugnant, Forbidden . . . and Designed 195
12. Free Markets and Market Design 217
Notes 233
Index 247

One surgeon's argument against compensating organ donors, but for removing financial disincentives

Here's another addition to the discussion of how and whether to incentivize live kidney donation, and/or remove financial disincentives to donating, by the medical director of Kidney and Pancreas Transplantation at New York Presbyterian Hospital/Columbia University Medical Center,


Cash for human kidneys: A bad idea is back, By David Jonathan Cohen, MD

Here's the part of his argument--about how incentives in a poorly regulated market could introduce lower quality kidneys from less medically qualified donors--that may be less familiar to readers of the "compensation for donors" posts on this blog. My comments follow...

"I’ve arrived at this position based on my three decades of experience as the medical director of one of the largest kidney transplant programs in the United States, performing more than 100 live donor transplants every year. In this role, as I examine potential live kidney donors, I have seen first-hand how far people will go to try to help loved ones. Many unsuitable donors try to persuade me to allow them to donate anyway, despite high medical risks. Others take steps even more extreme—and dangerous. Consider the 37-year-old woman who, without telling me, stopped her anti-depressants knowing that a history of depression might make her ineligible to donate to her friend. Or the 51-year-old cocaine addict who wanted to help her brother and forged a letter from her physician stating that the cocaine was treatment for a nasal condition. Had we not uncovered this, the outcome for donor and recipient would likely have been disastrous. 

Some go to other transplant centers and change their stories or covertly take medications to normalize their blood pressure or blood sugar in hopes of passing the evaluation, putting their own health at risk and potentially leading to the donation of unsuitable kidneys. 

Now imagine if there were a significant financial reward at stake, increasing the incentives to lie or dissemble. Many would surely do their best to disguise any medical conditions that might prevent them from donating in order to collect the reward, thereby adding to their own medical problems and potentially donating kidneys of lesser quality and thus harming the recipients. After all, they would now be donating to a stranger in order to enrich themselves or to address an urgent financial need, not to save a loved one. 

Doctors, too, would be confronted with terrible dilemmas. Take the potential donor who desperately needs cash or cash equivalent to prevent foreclosure on a home, pay for education for their children, or keep their business open. What is the responsible caring physician to do? It’s easy to say that this would not factor into a medical decision, but doctors are human. It’s hard to see how such considerations could be entirely avoided. " 

******************
This is just a small piece of the longer post, so take a look yourself.

I follow this whole debate closely, and I'm struck by how arguments about many aspects (both pro and con, or con and pro, depending on where you stand) are hampered by the lack of data. So arguments are theoretical, and it seems to me that many of the arguments used with confidence to support one conclusion could equally support the opposite.

Here, Dr Cohen notes the desperation which motivates the "many unsuitable donors" who would like to give a kidney to a loved one to conceal aspects of their medical history (so that they can donate anyway). He argues that would only get worse if kidneys could be purchased. (Just to fix ideas, let's suppose that kidneys could only be purchased by the Federal government, that they would be distributed as deceased donor kidneys now are--i.e. without too much regard to ability to pay--and that there would be stringent health checks before donation--and followup after.)  In such an environment, one could imagine that the need for potential donors to mis-represent their medical history would decrease, rather than increase, if, in this hypothetical world with payments, their loved ones would get transplants through the national system. (To be clear, I am also speaking here without data, since outside of Iran there aren't any legal markets for kidneys, and the Iranian market doesn't work at all like the hypothetical I've just described...)

Speaking of Iran, the same kind of argument-that-could-support-opposite-positions is made with respect to whether large monetary payments might 'coerce' unwilling or unsuitable donors to sell their kidneys. That's an interesting question, but Iranian surgeons have sensibly pointed out that there can be coercion without money: if your mom thinks you should give a kidney to your brother you might be coerced, and that kind of coercion might be decreased if kidneys were more available through e.g. a national market.

So...speaking as an experimental economist and market designer who has watched the waiting list for kidneys grow and grow (see my post on kidney statistics)...I'm increasingly inclined towards allowing the States to experiment cautiously with increasing incentives and removing disincentives to donation...

Four recent calls for removing disincentives for organ donation

There are a number of efforts underway to reduce the financial dis-incentives to kidney donation, with more or less emphasis on opposition to, and how removing dis-incentives is different from, compensating donors.

The first I'll mention is a March 13 blog post from Kenneth A. Newell, the president of the American Society for Transplantation:  Why all the talk about incentives?
Here's his whole post:

Last summer, the ASTS and the AST held a workshop to discuss the financial barriers faced by living organ donors. All of us who are engaged in the practice of living donor transplantation realize that the entire healthcare delivery system (providers, hospitals, insurers, and the government), as well as the recipient and society as a whole, benefits financially from the practice of living donation. Disturbingly, the donors are the group most at risk for adverse financial events. In many cases, donors incur expenses related to travel, meals, and lodging, as well as lost wages. In addition to these concrete financial consequences, living donors also face very real concerns about the loss of employment and the impact their donation will have on future insurability. Programs such as the HRSA-funded National Living Donor Assistance Center (NLDAC) provide critical support to those donors with the most extreme financial need, but this support is limited to travel and travel-related expenses.

The aim of the first meeting was to explore whether the AST and the ASTS could articulate a common vision on the topic of financial disincentives and incentives as they pertain to organ donation. The two societies agreed to work to remove all financial disincentives to organ donation, and consider pilot projects to study what some might consider to be true incentives. These ideas are more fully articulated in a New York Times editorial authored by Daniel Salomon and Alan Langnas, as well as in a manuscript soon to be published in the American Journal of Transplantation.

As a second step, representatives of the two societies met last month in Minneapolis to discuss how the goals articulated at the first meeting could be operationalized. Presentation topics included the perspective of payers, overviews of NOTA and NLDAC, and consideration of how changes to NOTA could be effected. Attendees discussed where the societies might draw the line between the removal of disincentives and the provision of true incentives for living organ donation, and how an expanded program to remove all disincentives for all living donors might be administered (assuming that funding could be obtained). This second meeting focused almost entirely on the removal of financial disincentives with the goal of making the donor financially whole. This position was recently advanced by the AST Best Practices in Living Donation Consensus Conference. At this second meeting, there was little discussion about incentives or pilot projects to test the impact of true incentives, as these are more controversial and will require substantially more effort and time to engage a broader set of transplant stakeholders. In other words, both the AST and the ASTS agreed that the task of operationalizing the original workshop’s ideas must be strictly pragmatic and start with those changes that are largely agreed upon now: removing all disincentives.

So why all of the talk about incentives (and disincentives)? Because any changes to the current financial practices of organ donation will require the AST and the ASTS to engage in ongoing discussions with a larger set of stakeholders: patient groups, transplant professionals, government leaders, and society as a whole. Any changes must have the support of these groups as well as our membership, and any changes must meet the real needs of patients, donors and their families.

Over the next several months, the AST will reach out to our membership and these other groups to discuss the removal of financial disincentives, the definition of true incentives, and the challenge of possibly testing incentives in pilot projects. The conversation starts here: please share your opinions in the comment section.

Next, the open letter linked and excerpted below, is from the Declaration of Istanbul Custodian Group and signed by many prominent opponents of compensation to donors: the first signer is Frank Delmonico.
An Open Letter to HHS Secretary Burwell on Ethically Increasing Organ Donation

"In 1984, Congress passed the National Organ Transplant Act (NOTA). That statute not only established the Organ Procurement and Transplantation Network but also enshrined in law a principle that had guided the development of organ transplantation worldwide over the previous 30 years: organs from living and deceased donors are precious gifts, and should not be bought and sold as market commodities.

Remove the Obstacles to Donation

The growing demand for transplants currently exceeds the supply of donated organs. In the previous decade, a collaborative effort among the Department of Health and Human Services, organ procurement organizations, physicians, and community groups produced a 25% increase in the number of deceased donor organs. Yet, over the course of the past ten years in the United States, the number of kidney transplants (which account for more than two thirds of all transplants) made possible by living donors has declined by approximately by a thousand.One major reason for this decline is that living donors in the United States incur on average more than U.S. $6000 in out-of-pocket costs. Potential donors may not be able to afford these expenses and may either be unaware of, or not meet the strict requirements for, programs that cover some but not all of donors' financial costs and losses.If the United States wants to increase organ donation, we should begin by removing these financial disincentives. We are aware that some people have recently called on the President and Congress to repeal, or at least suspend, NOTA's prohibition on paying organ donors. However, when it looked at “Ways to Reduce the Kidney Shortage” (September 2, 2014), the New York Times rightly concluded that “there are lots of reforms that could be made without resorting to paying for kidneys.”

The post goes, on, you should read the whole thing, but here are the two concluding section heads:
Appoint a New Task Force on Organ Donation and Transplantation
and
Financial Incentives for Donation Would Violate Global Standards and Will Not Work
****************

Below is a statement from an organization whose very name reflects the complicated politics: it is called STOP ORGAN TRAFFICKING NOW!, and it describes its goal as "Working to Remove Barriers to Living Donations". That is, it is an organization seeking to remove disincentives to donation, that wants to distinguish itself from black markets, and perhaps from those proposing compensation. (Forming coalitions is hard, and politics is incremental...)

The SOTN Proposal In Simplest Terms
"• Increase penalties for organ brokering at home and abroad.
• Follow original intent of NOTA and have Medicare help patients in greatest medical need first and according to UNOS current wait list criteria by:
(a) paying expenses of donors willing to give to top match in their region, and
(b) paying the Organ Procurement Organizations (OPOs), which currently match deceased donor organs with recipients, to arrange living matches as well.
• Allow 501(c)(3) public charities (and recipients themselves) to cover all donation related expenses – The same expenses that currently can be deducted from state income taxes at the state level. Charities can help any donor, not just those giving to front of the list.
• Create living donor registry that puts donor AND one relative to the front of the list at any time donor chooses."
**************

Finally, I'm keeping an eye on a newly formed organization called Waitlist Zero, in part because its co-founder and executive director is Josh Morrison, a young lawyer and kidney donor (who thinks of kidney donation as an example of effective altruism), with whom I had the privilege to work when he was the general counsel at the Alliance for Paired Donation (Mike Rees' kidney exchange organization).

Here is their statement of goals, principles and policies:

Our Goals. We come together as a coalition to advocate that the Health Resources and Services Administration:

1. Publicly support the goal of increasing living kidney donation;
2. Allow grant funding, including that pursuant to 42 U.S. Code §274f–1(b), to go to projects intended to increase living kidney donation;
3. Allocate such funds in rough parity between living and deceased donation projects; and
4. Include metrics and goals related to the increase of living donation on HRSA’s FY 2016 Annual Performance Report.

Our Principles. Collectively, the Coalition believes:

• Deceased donation alone can never end the deadly kidney shortage, and any policy that takes that shortage as given is morally unacceptable.
• Living donation is a noble choice that is not right for everyone, but donors themselves can benefit from the better health of their loved ones and the psychic gains to donation. Since studies show the vast majority of living donors do not regret donating, federal policy should presume donation to be a positive choice worth promoting.
• Informed consent must be maintained for every kidney transplant. Any effort to coerce or pressure someone into donating is unacceptable.
• Improvements are always possible, but the current transplant system does an excellent job of ensuring informed consent for the thousands of living donors who give each year.
• Government programs to increase living donation should not and will not impinge on the ability of transplant centers to ensure informed consent and guarantee the absence of coercion.

Our Policies. Collectively, the Coalition hopes that HRSA’s support for increasing living kidney donation will lead to policies along the lines of the following:

• Donors should not be worse off for having donated. Government should: (1) guarantee the reimbursement of donor lost wages, (2) provide health insurance coverage to alleviate risks of donation, and (3) devote appropriate resources to ensure long-term donor follow-up.
• Transplant awareness and education should be increased for the public, patients, and patient families. All patients and patient families should receive comprehensive transplant education before they go on dialysis (when possible) and immediately thereafter (when necessary). Access to paired kidney donation should be universal.
• Members of the Coalition may have different views as to the advisability of incentives for living donation, but the Coalition believes there are many ways the federal government can increase living donation that do not raise the controversy of incentives, and this campaign is not intended to promote the adoption of incentives.

HT: Frank McCormick, et al.

WSJ channels Nikhil Agarwal on salaries of medical residents

Here’s the Real Reason Medical Residents Make Just $47,000 a Year, Study Suggests

"In an upcoming paper in the American Economic Review, Dr. Agarwal argues thatstudents are willing to take a hefty pay cut to end up at a prestigious residency, and this lowers resident salaries by an average of $23,000 annually for all programs. In 2010, the average medical resident made about $47,000 a year, while physician assistants made about $86,000.

“The matching algorithm results in very efficient allocations and a very timely and well-functional market, but people have been resistant to using it because of this issue–they fear that it might negatively affect salaries,” Dr. Agarwal said. “After this paper, we learned that the fact that salaries are low in the medical residency market has nothing to do with the algorithm itself. Rather, it’s because of fundamental economic forces, like the limited number of positions at fantastic hospitals.”

In the medical-residency market, students and residency programs both rank their top choices, and are then matched using this algorithm. In 2012, Alvin Roth and Lloyd Shapley received the Nobel Prize in economics in part for their work creating said algorithm, which is also used in areas such as matching students with public high schools.

A 2002 class-action lawsuit claimed that the medical residency algorithm violated antitrust laws and artificially lowered resident salaries, which are not negotiated between residents and programs. The lawsuit was dismissed after Congress made a special exception for the medical match program under antitrust law.

Dr. Agarwal’s paper finds that applicants are willing to pay an “implicit tuition”—defined as the difference between their actual salary and the salary their labor is worth–to have a prestigious and high-demand residency, such as those at Massachusetts General Hospital or Johns Hopkins Hospital. This keeps salaries low across the board, since all programs are able to levy an “implicit tuition” based on how desirable they are. The implicit tuition is the largest at the top.

“The top programs pay a little bit more than the average programs, but there’s a sense in which their salaries are low relative to the value of the medical resident labor they’re getting,” he said.

Dr. Agarwal used data collected from 2003 to 2011 by the National Graduate Medical Education census. He knew only the outcomes and not how the residents and programs ranked each other.

However, programs that hire multiple residents reveal a lot about their preferences. By comparing the profiles of the residents ultimately accepted by a program, he could infer which factors–such as licensing scores or educational prestige–the program valued most in the admissions process. After doing this for various programs, he was then able to figure out which options a given resident was likely to have had, and estimate the demand for each position.

Since the number of positions is limited relative to demand, more positions at these top residencies would mean the programs will have to compete with each other, therefore increasing salaries, he explained."

Compensating donors for a different kind of transplant

You Can Sell Your Poop For $13k Per Year And Help Science

"In the spirit of one man’s trash being another man’s treasure, the non-profit companyOpenBiome is actually paying for stool samples in order to create lifesaving fecal transplant treatments for those infected with Clostridium difficile, a bacteria which is highly resistant to antibiotics.

Infections of C. difficile result in severe diarrhea, hospitalizing 250,000 Americans each year and causing about 14,000 deaths. It can actually come about after using antibiotics for too long, which ties into what makes it exceptionally difficult to treat. The patient’s gut microbiota is nearly wiped out, and conventional probiotics are not sufficient to replace them. 

The best treatment for C. difficile infections is a fecal transplant, and yes, it has traditionally been as horrible as it sounds. Doctors have relied on highly invasive nasogastric tubes (NG tubes) or colonoscopies to put donor fecal matter into the gut of their infected patients. As difficult as the process may be, it is highly successful. A new method uses capsules of frozen fecal matter, which thaw out in the body and release the contents in the small intestines. The success rates of the capsules is comparable to traditional treatments, around 90 percent. 

These frozen fecal capsules are OpenBiome’s wheelhouse, as they collect and screen stool samples, and turn them into the ready-to-administer treatments for hospitals. Of course, the feces needs to be sourced from somewhere. OpenBiome pays donors who are committed to providing multiple samples per week.

Though everybody may do it, not everyone is an ideal candidate to get paid to do it. First and foremost, OpenBiome needs donors to be near their lab in Medford, Massachusetts to join the registry to donate. Candidates who meet the requirements for age, BMI, and health pre-screening questions are then invited to get blood and stool testing. Donations are then made at least four times per week for 60 days, when each donor is re-evaluated. Once the next round of blood and stool tests come back clear, the previous samples are then converted into capsules and sent to patients across the country.

The going rate is $40 per donation, with a $50 kicker for those who come five days a week. This translates into $250 per week, or $13,000 per year. OpenBiome tries to make the experience as fun as they can by offering prizes to donors who make the most donations, provide the biggest sample, etc. However, there’s no word on if OpenBiome offers a fun sticker to show off your donation to friends and family, such as the “Be nice to me, I gave blood today” badge handed out by the Red Cross. "

Legacy exhibition at the Nobel Museum in Stockholm

Legacy: 14 Nobel Laureates on inspiration, role models and the value of passing something on

A video exhibition by the artists David Hodge and Hi-Jin Kang Hodge will open at the Nobel museum in Stockholm on March 13 and run through November 15. I was interviewed for it at Stanford.

Here's a trailer for the video

I haven't seen the video of my interview, and don't remember well all the things we talked about, but this paragraph in the exhibition description could possiblyl refer to me talking about Lloyd Shapley:

"In one part of the exhibition, the video installation Legacy is shown, where Nobel Laureates discuss the importance of legacies, both personal and professional. One of the participants tells us that one of his greatest role models in science was a professor that he never worked with. But he was still inspired by their way of thinking and solving problems, methods that made such an impression of him that he in turn could use them for problem solving in other fields. "

Market design and repugnance interview, in Japanese

For readers of this blog who might like to read an interview in Japanese, here is one that includes discussion of both market design and repugnant transactions, by Ayako Hirono of Nikkei Business.

ノーベル賞経済学者が挑む「禁断の取引」

アルビン・ロス米スタンフォード大学教授に聞く

Sally Satel on compensation for kidney donors

Sally Satel, in the Pacific Standard, makes the case for compensating kidney donors, illustrated with a photo including the first organ donor, Richard Herrick, who gave a kidney to his identical twin brother in 1954 (and passed away in 2010):

The Case for Compensating Kidney Donors
"Our current system is failing dramatically because altruism isn’t a sufficiently motivating force to give up an organ. We need to test incentives, to reward people who are willing to save the life of a stranger through donation."

Dr. John P. Merrill (left) explains the workings of a then-new machine called an artificial kidney to Richard Herrick (middle) and his brother Ronald (right). The Herrick twin brothers were the subjects of the world's first successful kidney transplant, Ronald being the donor.

Reflections on practical market design, by Moritz Hardt

Moritz Hardt reflects on the political parts of market design, in connection with some of his (more or less) recent, discouraging experience in proposing its use to the California Public Utilities Commission: Towards practicing differential privacy.

Long story short, the CPUC decided not to give data to some users rather than to adopt a privacy standard that would have allowed those users to get useful data.

It's a long post, well worth reading, about what went wrong and what could have been done better. I'll just summarize some of his subject headings, as he thinks about how he'll go about this in the future, in the second part of his post, called On practicing differential privacy:

Focus on win-win applications
"Apply differential privacy as a tool to provide access to data where currently access is problematic due to privacy regulations. Don’t fight the data analyst. Don’t play the moral police. Imagine you are the analyst
....
Don’t empower the naysayers
"for differential privacy to be a major success in practice it would be sufficient if it were successful in some applications but certainly not in all—not even in most.
...
Change your narrative
"Don’t present differential privacy as a fear inducing crypto hammer designed to obfuscate data access. That’s not what it is. Differential privacy is a rigorous way of doing machine learning, not a way of preventing machine learning from being done.
...
Build reliable code repositories
"A weakness of the differential privacy community has been the scarcity of available high quality code.
...
Be less general and more domain-specific
"... reading the scientific literature on differential privacy from the point of view of a domain expert can be very frustrating. Most papers start with toy examples that make perfect sense on a theoretical level, but will appear alarmingly naïve to a domain expert.
...
Be more entrepreneurial
"The CPUC case highlighted that the application of differential privacy in practice can fail as a result of many non-technical issues. These important issues are often not on the radar of academic researchers.
...
So, is differential privacy practical?
"I like the answer Aaron Roth gave when I asked him: It's within striking distance."

Delay in Boston school choice this year

Here's the story in the Boston Herald: BPS apologizes 
for Boston schools lottery hang-up

"Incoming school Superintendent Tommy Chang says he wants all city parents to enroll their children in Boston Public Schools — but a glitch in the BPS lottery this spring will delay choices for many families until long after most private and charter schools have sent out acceptance letters and expect an answer.

Chang told Boston Herald Radio’s “Morning Meeting” yesterday, “I think Boston Public Schools need to be an option for all parents.”

Chang, currently a superintendent in Los Angeles schools, will take the Hub post in July pending school committee approval.

In an automated call Sunday, the district notified registrants for grades K, 6 and 9 that they won’t receive their fall assignments until early April, after the School Committee votes on March 25 whether to close Elihu Greenwood Leadership Academy, Rogers Middle School, West Roxbury Academy, Community Academy and the Middle School Academy program.

“We completely understand and apologize for the delay,” said district spokeswoman Denise Snyder. “We try very hard to coordinate our timeline for (school) assignments, understanding that families have several educational options and it’s hard for them if the results are not all aligned. ... But if we did not delay the (school assignment) round, many families could have ended up in a school that was closing.”

Jon Clark, co-director of three K-8 Brooke Charter Schools in Boston, said their school lotteries, like those of many other charter schools, are tomorrow, acceptances will be mailed the following day, and parents will have until March 18 to respond.

“We aren’t unfortunately coordinated (with Boston Public Schools) in any meaningful way,” Clark said. “If we had a common system, we could make it more simple for parents.”

Many private schools mail acceptance letters this week and expect an answer and deposit by early April."
**************

Boston district schools use a centralized clearinghouse run by a deferred acceptance algorithm to match children to public schools, but they don't yet have a single application system that includes the charter schools, hence this kind of snafu is possible... A number of cities have coordinated the district and charter schools in a single application process, and the quote above from the charter school director Mr Clark makes me optimistic that this may be politically possible in Boston under the new Superintendent.

Breast milk plan to purchase and sell breast milk cancelled in Detroit

Steve Leider writes:

"An Oregon-based company Medolac (partnering with the Mothers Milk Cooperative) was trying to expand its program of buying breastmilk from nursing mothers with surplus milk into Detroit.  However, several local groups reacted very negatively, arguing that this would cause many mothers to sell all their milk (therefore harming their own children).  Ultimately it caused the company to cancel their plans."

Here's a positive story on the proposal, focusing on a seller of breast milk (who produced more than her baby could consume), followed by many negative stories (focusing on the possibility that women would sell breast milk even if they did not have a surplus):

 Breast milk company cancels campaign to recruit Detroit moms

"She breast-fed Jaden, but when Johanna was born, she wouldn’t latch on to breast-feed.

So Short was getting up at 4 am to pump and put that milk the in the freezer. Eventually, she said she wound up with an overflowing freezer stuffed with 2,000 ounces of breast milk.

"I had a storage problem! I just didn't have anywhere else to put more frozen milk," she laughs. 

For a while, Short was donating that milk to a local, non-profit milk bank.

But a friend told her about Medolac, which pays moms $1 an ounce for breast milk.

The company says it then sells that milk, at a profit, to hospitals, where it helps premature babies.

Over the next nine months or so, Short says she sent about 5,400 ounces to Medolac.

"It did help cover some bills. I bought myself a porch swing! That was my treat to myself because I really wanted a porch swing! And we definitely paid bills with it. There was a time when my husband was working fewer hours, so it really helped us cover bills."

And, Short says she originally planned to stop breastfeeding Johanna after a year. But she's continued, because of Medolac.

"It was a great incentive for me to continue and make a little bit of extra money and help some other babies who need it."

**************

Detroit moms protest breast milk banking effort

"A group of Detroit women is accusing an Oregon breast milk bank of exploiting women by asking them for their breast milk — a particular concern given the city's deep poverty, low rates of breastfeeding and high infant mortality.

That effort, they say, will take the precious substance — packed with potentially life-saving health benefits — away from Detroit babies."

*******************

 Company offering to buy breast milk creates controversy (video of news broadcast, with interviews)

*******************

Oregon firm drops plan to buy Detroit breast milk

"An Oregon-based company has backed away from a plan to purchase breast milk from Detroit mothers, saying Thursday that opposition from community groups made the environment here “toxic.”

"Detroit organizations unleashed a firestorm of questions last week and argued the plan by Medolac Laboratories smacked of exploitation of the city’s impoverished mothers. Detroit has the highest infant mortality rate in the nation, as well as the greatest percentage of children living in extreme poverty.

...

"Kiddada Green, executive director of the Black Mothers Breast Feeding Association, called the Lake Oswego company’s decision not to collect breast milk in Detroit a “victory to Detroit mothers.”

Tommy Andersson.on the prospects for kidney exchange in Scandinavia

Tommy Andersson talks to Swedish radio about kidney exchange: Matematisk modell kan lindra organbrist (Google translate: Mathematical model can alleviate the organ shortage)

"More than 600 people are now on the waiting list to get a new kidney and organ shortage that the waiting time for a kidney transplant is more than two years. Question is about the work that Swedish transplant hospital and economists at Lund now start doing that one can say that it is really about mathematics that saves lives.

- If everything goes as it should, we expect to increase the number of kidney transplants in Sweden by 10-15 per cent a couple of years. In this sense, it literally saves lives, says Associate Professor Tommy Andersson."