Transplant surgeons reject 45% of offered livers to protect program metrics

CMS flags transplant programs whose post-transplant survival falls below expected thresholds, and roughly one-third of all US transplant programs get flagged every three years. When a program is flagged, transplant volume drops 38% as the program faces potential decertification. This creates a perverse incentive: surgeons decline marginally viable organs not because the patient would do poorly, but because a single bad outcome could tank the program's statistics and threaten its existence. The result is that organ offer acceptance rates vary wildly across centers (12%-62% for hearts), and for every 5% decrease in a center's acceptance rate, there is a 27% increased odds of waitlist mortality. Patients die waiting because their transplant center is optimizing for regulatory survival, not patient survival. This persists because CMS still uses blunt outcome-based metrics that penalize programs for taking on high-risk transplants, even when the alternative is the patient dying on the waitlist. A new offer acceptance rate ratio metric took effect in July 2023, but it measures a different dimension and does not eliminate the survival-rate penalty that drives risk aversion.