OPOs are reimbursed for whatever they spend regardless of how many organs they recover, so the worst-performing OPOs have no financial incentive to improve and none has ever been defunded until 2025

Organ procurement organizations are among the last entities in U.S. healthcare funded on a pure cost-reimbursement basis. They are not paid per organ recovered. They are not paid based on transplant outcomes. They submit their costs to Medicare, and Medicare reimburses them. An OPO that recovers organs from 1 in 4 potential donors receives the same type of funding as one that recovers from 3 in 4. CMS found in its own assessments that 74% of OPOs were failing performance standards. Despite this, not a single OPO lost its contract until HHS moved to decertify the Life Alliance Organ Recovery Agency at the University of Miami in 2025 — the first decertification in the program's entire history. So what? Without financial consequences for poor performance, the lowest-performing OPOs have no external pressure to improve. As many as 28,000 viable organs fail to reach patients annually, with some of the worst OPOs recovering organs from only 25% of potential donors. These are not organs that are medically unsuitable — they are organs from patients who died in donation-eligible circumstances, in hospitals within the OPO's territory, where the OPO simply failed to identify the donor, failed to approach the family, or failed to coordinate recovery in time. So what? A Senate investigation by Senators Wyden and Grassley confirmed instances of waste, fraud, and abuse across OPOs nationally. Some OPOs gamed their performance metrics to appear compliant while underperforming on actual organ recovery. HHS investigators found that at one OPO, at least 28 patients may not have been deceased at the time of organ preparation, and 73 patients showed neurological signs incompatible with donation — suggesting that the pressure to hit numbers led to cutting corners on patient safety rather than genuinely improving recovery rates. This problem persists because each OPO holds a geographic monopoly — there is no competing OPO that a hospital or CMS can switch to. The regulatory framework was designed in 1984 and has barely evolved since. Cost-reimbursement was chosen because organ procurement was seen as a public service that should not be profit-driven, but the result is a system where the financial model actively insulates underperformers from accountability. The 2025 decertification of Life Alliance may signal a shift, but it took four decades and congressional pressure to achieve a single enforcement action.