1 2 3 4 Diagnosis and Referral for Transplant Evaluation To join a transplant waiting list, patients must be referred by a doctor or other care provider to a specialist who can evaluate them. This evaluation determines whether they are able to join a transplant list. STEP ONE Transplant List Individuals in need of a transplant of a deceased donor organ are added to a waiting list. Transplant waiting lists prioritize patients based on medical urgency and other factors, although the measures used to determine urgency are different for each organ. STEP TWO Organ Donation The success of the U.S. deceased donor organ transplant system depends on the generosity of individuals and their families who, at the time of death, make the decision to donate organs to someone they have never met. Without these donations, organ transplants would not be possible. STEP THREE Organ Transplantation Once a prospective recipient is found for a donated organ, an organ offer is sent to the recipient via the care team at their transplant center. The decision to accept or reject an organ offer is usually made by the transplant center, without the patient’s knowledge or input. STEP FOUR

Coordination, Payment, and Outcome Monitoring

The current organ transplant system is unduly fragmented and inefficient. Its components operate largely independently of one another, and there is no organization or entity responsible for overseeing the performance of the organ transplant system as a whole. If the different entities in the organ transplant system operated in a more coordinated fashion with common goals and unified policies and processes, it could save additional lives and be more equitable. The organ transplant system is overseen by several government agencies such as CMS and HHS, which are ideally positioned to take actions that will increase the coordination, efficiency, and equity of the transplantation system.

Action HHS should set goals for the transplant system as a whole based on the performance of its best-performing donor hospitals, OPOs, and transplant centers in equity, organ donation rates, procurement and transplantation of organs from donors after circulatory determination of death (DCDD), acceptance of offered organs, and low rates of nonuse of donated organs. These goals should include:

  • Improve donation and transplantation rates among minority populations and disadvantaged populations based on the proven practices of donor hospitals, OPOs, and transplant centers which are most successful in these areas.
  • Increase the number of organs procured from medically complex donors, including DCDD donors.
  • Improve offer acceptance levels for each organ type to those achieved by the 5 to 10 percent highest-performing transplant centers for that organ type nationally.
  • Increase the number of transplants to at least 50,000 by 2026.

The behavior of organ procurement organizations, transplant centers, and other actors in the transplant space is determined largely by CMS’ reimbursement policies. CMS can alter these reimbursement policies to incentivize behavior that improves the number of organs transplanted and promotes equity in the transplant system.


CMS should adopt payment policies that incentivize all providers – from primary and specialty care of patients with organ failure to referral for transplant, care while awaiting a transplant, and long-term posttransplant care – to improve the number of transplants performed, equity in access to care, and outcomes for patients. These could include:

  • eliminating disincentives for transplant centers to transfer donors to a DCU,
  • increasing reimbursement for referral for transplant evaluation for all organ types,
  • incentivizing hospitals to smooth surgical scheduling to ensure the capacity to recover and transplant donated organs, and
  • incentivizing organ procurement from DCDD donors.
We call on you to think of standing the system on its head and reconceptualize the care of patients with organ failure. And maybe as a revolutionary thought, we should actually ask the patients with organ failure and kidney disease to design what they need to be measured to achieve their benefit.”

Osama Gaber, Chair, Houston Methodist Department of Surgery and President (2021-2022), American Society of Transplant Surgeons (ASTS)
Trust underlies the entire organ and tissue donation and transplantation environment, and everyone must act to obtain, sustain, and nurture that trust among those directly and indirectly affected.”

Kenneth Moritsugu, donor family member
We need to stop incentivizing the practice of cherry picking and implement broad reimbursement across the board no matter what patient outcome statistics and allow patients to be the final decision maker in their care. ”

Fanny Vlahos, attorney; double lung transplant recipient; member of the Lung Transplant Initiative and Guidelines Committee, Cystic Fibrosis Foundation

Learn More

Realizing the Promise of Equity in the Organ Transplantation System (2022)