OPOs prioritize tissue recovery over organ procurement because tissue is more profitable, leaving organ donation understaffed at the critical moment

Organ Procurement Organizations (OPOs) in the United States are structured as 501(c)(3) nonprofits with a dual mandate: recover organs for transplantation and recover tissue (skin, bone, tendons, heart valves, corneas) for tissue banks. But the financial incentives are wildly misaligned. A single tissue donor can yield products worth tens of thousands of dollars to tissue processors — many of which are for-profit companies — and the volume of tissue donors vastly exceeds organ donors. The result, documented by reform advocates and congressional investigations, is that OPOs are often "grossly understaffed on frontline coordinators for organ donation, and heavily resourced and staffed for tissue recovery operations." This matters because organ donation is extraordinarily time-sensitive. When a potential organ donor is identified (typically a brain-dead patient in an ICU), a coordinator must respond within hours to evaluate the donor, approach the family for consent, manage the donor medically to preserve organ viability, coordinate with transplant centers, and orchestrate a complex surgical recovery. If the OPO's best coordinators are deployed on tissue cases — which are less time-critical because tissue can be recovered up to 24 hours after cardiac death — the organ case may be handled by less experienced staff, or the response may be delayed. Every hour of delay in organ donor management increases the risk of organ loss. Meanwhile, unlike organ allocation, which is governed by UNOS with transparent waitlist-based criteria, tissue allocation is entirely at the OPO's discretion. There is no regulatory requirement that recovered tissue benefit the community it came from, and no transparency about financial arrangements between OPOs and for-profit tissue processors. The structural root cause is a broken accountability model. OPOs have exclusive geographic monopolies — each region has exactly one OPO, and hospitals cannot choose a different one. Until 2020, OPOs essentially graded their own performance using self-reported data, and CMS had decertified only one OPO in 50+ years despite massive performance variation. The 2020 CMS rule introduced outcome-based metrics, but enforcement remains slow. Donor families are rarely told that their loved one's tissue may generate significant revenue for for-profit companies, and OPO financial disclosures do not clearly separate organ and tissue operations. Pro-transparency OPO leaders have called for CMS to require OPOs to publish financial relationships between OPOs, OPO leadership, and external tissue operations, but no such requirement exists.