Medical Governance

Medical Governance: Values, Expertise, and Interests in Organ Transplantation

David L. Weimer
Copyright Date: 2010
Pages: 232
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  • Book Info
    Medical Governance
    Book Description:

    Governments throughout the industrialized world make decisions that fundamentally affect the quality and accessibility of medical care. In the United States, despite the absence of universal health insurance, these decisions have great influence on the practice of medicine. In Medical Governance, David Weimer explores an alternative regulatory approach to medical care based on the delegation of decisions about the allocation of scarce medical resources to private nonprofit organizations. He investigates the specific development of rules for the U.S. organ transplant system and details the conversion of a voluntary network of transplant centers to one private rulemaker: the Organ Procurement and Transplantation Network (OPTN). As the case unfolds, Weimer demonstrates that the OPTN is more efficient, nimble, and better at making evidence-based decisions than a public agency; and the OPTN also protects accountability and the public interest more than private for-profit organizations. Weimer addresses similar governance arrangements as they could apply to other areas of medicine, including medical records and the control of Medicare expenditures, making this timely and useful case study a valuable resource for debates over restructuring the U.S. health care system.

    eISBN: 978-1-58901-682-8
    Subjects: Health Sciences

Table of Contents

  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-viii)
  3. Illustrations
    (pp. ix-x)
  4. Preface
    (pp. xi-xii)
  5. Acknowledgments
    (pp. xiii-xiv)
  6. Abbreviations and Acronyms
    (pp. xv-xvi)
  7. 1 Medical Governance: Important but Neglected
    (pp. 1-14)

    Governments throughout the industrialized world make decisions that fundamentally affect the quality and accessibility of medical care. In the United States, despite the absence of universal health insurance, these decisions have great influence on the practice of medicine, and, because of the absence of universal health insurance, occur in a great variety of institutional contexts. We see direct federal provision of medical care through the Veterans Administration, federal funding and regulation through Medicare, federal and state funding and regulation through Medicaid, federal funding of health services research, and state regulation of private group health insurance and entry into the health-related...

  8. 2 Balancing Values, Expertise, and Interests
    (pp. 15-42)

    The governance of the U.S. health care system is exceptionally complex and incorporates a great variety of institutional arrangements. Many of these regulate and subsidize market activity. Others seek to provide bureaus with the information and expertise they require to carry out their tasks but cannot easily collect or maintain in isolation from stakeholders. One goal of this chapter is to provide an overview of the ways these arrangements mediate values, interests, and expertise in medical governance. Another is to introduce and place in context the particular form of medical governance—private rulemaking—that is the empirical focus of this...

  9. 3 The Organ Procurement and Transplantation Network
    (pp. 43-56)

    Federal transplantation policy in the United States evolved to produce the Organ Procurement and Transplantation Network (OPTN) primarily in response to developments concerning two solid organs: kidneys and livers. Kidney transplantation initially became important because it is a lower-cost alternative to dialysis for end-stage renal disease (ESRD) that offers higher quality of life and greater longevity. Liver transplantation initially became important because of the publicity created by desperate parents seeking organ donations and financial support for transplantations needed to save the lives of those children. Although hearts, pancreases, intestines, and lungs are now commonly transplanted, livers and kidneys continue to...

  10. 4 Expanding Organ Supply
    (pp. 57-72)

    Perhaps within our lifetimes stem cell technology will allow new organs to be grown to specification so that cadaveric and live organ donation will no longer be necessary. Until then, however, the scarcity of organs for transplantation creates what Guido Calabresi and Philip Bobbitt famously called a tragic choice (1978). Indeed, the choice inherent in organ transplantation is driven by constraints, unlike Calabresi and Bobbitt’s canonical case of a limited supply of dialysis machines, that cannot be easily relaxed through additional investments of resources. Although the most controversial issues arising in the governance of organ transplantation have involved the allocation...

  11. 5 Liver Allocation and the Final Rule
    (pp. 73-96)

    The National Organ Transplant Act of 1984 transformed the voluntary network of organizations involved in solid organ transplantation into a formal network with effectively mandatory membership and governance by the OPTN. Since it began operations in 1986, the OPTN has exercised de facto authority over the content of rules governing the procurement and allocation of cadaveric organs. The de jure basis of this authority was disputed throughout the 1990s, but especially between 1994 and 2000, when HHS, which has oversight responsibility for the OPTN, developed and finalized rules that sought to impose specific allocation criteria on the OPTN and subject...

  12. 6 Incremental Response to Racial Disparity in Kidney Allocation
    (pp. 97-116)

    Good public policy strikes a reasoned balance among valid but usually competing social goals. Allocating transplant kidneys to maximize the chances that recipients survive is certainly desirable. Allocating them equitably is desirable as well. Yet these goals may conflict in a variety of ways. Most prominently, medical efficacy and equity of access have come into conflict over decisions about how much weight to place on antigen matching between deceased donors and kidney transplant recipients in allocation rules. Although antigen matching increases graft and transplant survival rates, it reduces the opportunities for African Americans to receive timely transplants. The responses of...

  13. 7 The Kidney Allocation Review: Can the OPTN Make Nonincremental Change?
    (pp. 117-134)

    The modifications made to liver allocation rules during the Final Rule controversy and to kidney allocation rules in response to concerns about racial disparity show the capacity of the OPTN for using statistical evidence, working with the SRTR to conduct sophisticated policy simulations, confronting value conflicts, and assessing the tacit knowledge of transplant professionals to support and make incremental change. In the case of liver allocation, the cumulative effects of the incremental changes eventually resulted in a substantially different allocation system. In the case of kidney allocation, a large number of small changes were made within the framework of the...

  14. 8 How and How Well Does the OPTN Govern?
    (pp. 135-146)

    Like zoologists sizing up unfamiliar animals, the previous chapters in this volume have tried to put the OPTN into an appropriate and useful category and then to observe its operations to understand how it functions in its environment. Whereas zoologists generally do not concern themselves with normative questions about the goodness of the animal in its niche, we want to know if the OPTN governs well. Doing so requires, first, an overall assessment of how the OPTN produces and administers policy, and, second, an evaluation of the extent to which these policies promote appropriate social goals. Completing these tasks sets...

  15. 9 Is the OPTN a Viable and Desirable Model in other Medical Contexts?
    (pp. 147-168)

    Every form of governance has strengths and weaknesses. I believe that the account of the OPTN shows that it offers a favorable balance of strengths over weaknesses for setting and implementing organ transplantation policy. Most important, it is quite an effective arrangement for integrating expertise, values, and interests. It is exemplary in bringing evidence and tacit knowledge to rulemaking. It also is commendable in promoting the consideration of competing values, although the predominant process of incremental change from initially adopted rules tends to result in relatively slow responses to concerns that particular values are receiving too little weight. With the...

  16. References
    (pp. 169-194)
  17. Index
    (pp. 195-214)