Gaming the Liver Transplant Market

The liver transplant waiting list is designed to allocate livers to the sickest patients first. Before March 1, 2002, livers were allocated to patients based on objective clinical indicators and subjective factors. In particular, a center placing a prospective transplant recipient in the intensive care unit (ICU) leads to a higher position on the liver transplant waiting list. After March 1, 2002, a policy reform mandated that priority on the liver transplant waiting list no longer be influenced by whether the patient was in the ICU. I show that after the reform, ICU usage declined most precipitously in areas with multiple transplant centers. I find no evidence that pervasive manipulation in the most crowded liver transplant markets distorted the allocation of livers away from the intended prioritization of the sickest patients first. It appears that centers in areas with multiple competitors manipulated the waiting list to ensure that the sickest patients received a liver.