Heart transplant waitlist gaming: patients get invasive treatments to jump tiers

The six-tier heart allocation system implemented in 2018 was designed to prioritize the sickest patients, but transplant programs have learned to game it by giving patients invasive treatments—such as intra-aortic balloon pumps or temporary mechanical circulatory support devices—that their clinical condition may not warrant, solely to push them into a higher-priority tier. A patient who might safely wait with medication gets an invasive device implanted, with its own risks of infection, bleeding, and complications, just so their transplant center can move them from Status 4 to Status 2. This undermines the entire allocation system because priority is determined by treatment intensity rather than actual medical urgency, and it exposes patients to unnecessary procedural risk. UNOS and transplant physicians recognized this problem and began developing a continuous distribution score based on objective test results—similar to the lung allocation score that successfully reduced gaming in lung transplantation. However, federal agencies directed UNOS to pause development of this scoring system to redirect resources toward investigating rare organ procurement mistakes, leaving the gaming problem unresolved. The structural reason gaming persists is that each transplant center is individually incentivized to escalate their own patients, and there is no penalty for over-treating to gain priority.