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Remove disincentives to using older and more complex donors when appropriate


Automate real-time donor referral

Establish better metrics

Get the right organ to the right patient

Remove disincentives

Enable OPOs to merge or share services

Save even more lives

The U.S. has the highest performing donation and transplant system in the world. But as good as it is, it needs to get even better to support the more than 100,000 patients on the waiting list. Based on the input of experts in our field, UNOS is proposing a five-part package of reforms to drive improvements to save even more lives.


America has the highest performing organ donation and transplant system in the world. We have more organ donors and more annual transplants, and we save more lives through organ donation than any other country. Still, there are ways to increase the number of transplants and help even more people. One key step toward increasing organ transplantation is to use organs from older donors, whose organs are often rejected by transplant hospitals because they are more complex to work with. For some transplant patients, especially those who are older themselves, organs from older donors are a good choice. Though receiving an older donor’s organ can create more expensive post-transplant care than getting a younger donor’s organ, it is, in many cases, less costly than dealing with a chronic condition. For example, 62% of kidneys with medical characteristics that transplant hospitals commonly reject and discard are used in France.


Evaluate transplant hospitals based on their use of organs from older and more complex donors and eliminate monitoring and financial disincentives for using these organs.


UNOS will review transplant hospital outcome metrics and ensure that risk factors associated with complex donor organs and recipients are accounted for.

CMS, which uses risk adjustment in evaluating transplant hospital performance, should also use statistical risk assessment to align payments to hospitals with the complexity of the organs they choose to transplant. Some donor organs and some recipients can be expected to require longer hospital stays or additional care. Payment formulas should remove disincentives for taking on additional predictable expense. A leadership role in this approach by CMS might also help encourage private payers to consider doing the same.

Originally published on Sept. 15, 2020; updated Dec. 5, 2020

1 million transplants

The U.S. surpassed 1 million transplants in 2022

The gifts of generous donors and their courageous families made several lifesaving transplant records possible.


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Benefits of using complex organs

  • Increases the pool of available organs.
  • Ensures more people can receive the lifesaving transplants they need and more donor families can give the gift of life.
  • Reduces obstacles and waiting times for a transplant.

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