The lower “cost” of bone marrow donation: freshly minted research out on donor (dis)incentives

Paying bone marrow or organ donors is still a hot button issue.  Ethical qualms aside, the core question surrounding this issue is whether such monetary incentives, or less drastic incentives like tax breaks, are actually effective enough to encourage more donors to register. But a less divisive and perhaps less public donor benefit has been a removal of various disincentives (potential barriers to donation). Donor recruitment stakeholders identified potential lost wages as a key disincentive for donors who would need to take time off of work in order to donate. This resulted in a wave of legislation requiring employers to give their employees paid leave if they are donating bone marrow or organs. And again, at the heart of these initiatives is the question of how effective this has been in increasing donation rates.  Thankfully, there is new research in health economics that seeks to answer this crucial efficacy question.

A newly released study analyzes the impacts of leave and tax legislation on both living (organ and bone marrow) and deceased donation rates (organ only)(Lacetera et al 2012). You can access the full working paper describing the research findings. Additionally, NPR had some recent summary coverage of another free full text article that presents research examining the effect of tax deduction incentives (offsetting various costs of donation–transport, medical expenses, etc.) on organ donation rates (Venkataramani et al 2012).

death and taxes book cover

Death and taxes? The relationship isn’t so clear in transplantation (Source: lucyfrench123, Flickr)

This blog, as many readers know, is supported by the Asian American Donor Program (AADP), an organization that was instrumental in the passage of the California’s most recent leave legislation, The Michelle Maykin Memorial Donation Protection Act. It added paid leave for nearly all bone marrow and organ donors to the already enacted leave legislation for state employees. We are therefore extremely interested in whether such legislation has made an impact.

Minimal impact does not mean abandonment, it means improvement

The Lacetera et al publication offers some positive results that such legislation has been modestly effective in promoting more bone marrow donations but there is not the same effect evident in organ donation. By specifically scrutinizing bone marrow donation for the first time, the research “supports an ‘incentive size’ explanation for the zero result on organs, namely that the incentives may be too low for more ‘costly’ donations but may work for less invasive procedures” (ibid, 4). Since there is a lower cost to the living bone marrow donor than an organ donor, the effectiveness of these incentives may vary. This is in keeping with existing literature on the positive effect on blood donation in a similar study.

And while both studies assert that legislated incentives do not show a statistically significant positive effect on organ donation donation rates, this is a hardly a reason to dismiss these kinds of initiatives. Rather, it is a compelling reason to improve their formulation and implementation. Even with no significant increase in number of donors/transplants, the data used nor its analysis measures other externalities which produce better tracking and treatment of donors, aside from the quality of the organ supply using post-transplant survival rates. This brings up the issue of whether every incentive or removal of disincentive has to necessarily increase the donor pool in order to be worthwhile. In fact, Venkataramani et al makes this point in their article’s discussion of other possible benefits of the legislation like donor quality of life that their study does not explore further. Dr. Venkataramani also concludes more accessibly in his blog post about his research:

First off, tax deductions don’t put that much money back in your pocket. For an upper middle class family of four, the value of a deduction amounts to $500-$900. Nothing to sneer at, but still below the estimated (opportunity) cost of making a donation. We argue that tax credits (which have a higher cash value) or grants may work better. Second, in doing the research we ended up talking to organ donation activists in many states, many of whom had no idea these policies were in place! It’s possible that a lack of awareness led to our null finding, as well. Finally, while we don’t elaborate on this in the paper, our Figure 1 shows that states that passed these laws experienced increasing donation rates relative to the other set of states prior to the passage of the laws. So it’s possible that states that were progressive enough to pass tax deductions were already doing other things to bump up donation rates.

Finally, while tax deductions may not lead to new donors, they may be helping people who would donate anyway.

While at a glance the headlines may imply the donation rate is the metric we should always focus on, the existing donor pool also deserves better monitoring and provisions to protect them under the law and in policy. Although both articles’ central concern is the positive effect on the number of donors, they do entertain the possible collateral social benefits that such legislative acts may also produce. But the analysis stops short of suggesting more strongly how the dissemination of these dis/incentives will be shared effectively in a population. The authors do point this out as a possible confounding factor in determining significance, but I would call for these issues to be examined more deeply. It would also be useful to make comparison of how effective different education measures have been in introducing the new incentivizing legislation. Lacetera et al also suggest that more widely educating donation advocates and the public at large that would work well given their results:

…it is possible that not enough people are aware of the existence of the legislation. UNOS, for example, does not mention these types of legislation in its summary of information for prospective living organ donors. (The NMDP does, however, mention the existence of laws providing leave to donors, which also could help explain the stronger effect of these types of legislation on bone marrow donations.) Second, the results could be confounded by the existence of grant programs, which already may be providing the same cost reimbursement as the tax laws. Employer-specific paid leave programs could further be diminishing the effect of leave laws. Third, a composition effect might be occurring, whereby some subsets of the population are positively motivated by these additional incentives to donate (on top of their intrinsic motives) whereas others are “crowded out” (because their self or social image may be tainted [Benabou and Tirole, 2006] or because they consider the presence of material incentives repugnant [Roth, 2007]). Fourth, the incentives put in place by these types of legislation might not be strong enough to induce an individual, who is not otherwise sufficiently altruistically motivated, to endure the pain, suffering, scarring, time away from work and leisure, and undocumented long-term donor health effects implied by an organ donation. Some evidence also exists that donors occasionally have difficulty obtaining life and health insurance post-donation (Rudow et al., 2006; Spital and Jacobs, 2002).31 Untangling these explanations is of importance for policymakers interested in increasing and enhancing the supply of organs for transplantation.

It may be a bit disappointing to learn that the latest research on the adoption of  leave legislation and/or tax deductions show little to no effect on donation rates. But both of these featured articles make it very clear that this does not mean we should abandon these types of measures. Though it does highlight how we need to revise the content and implementation. Not only is it a question of the magnitude of the incentive offered or the size the measure offsetting a disincentive, it is also about how to better educate donor recruitment professionals and educators themselves about these legislative benefits. This research also prompts us to re-think how we evaluate effectiveness. If we only focus on the number of donors as the bottom line, we could very easily miss all the other possible positive effects on the donor pool.

Works Cited

Lacetera, Nicola, Macis, Mario and Stith, Sarah, Removing Financial Barriers to Organ and Bone Marrow Donation: the Effect of Leave and Tax Legislation in the U.S (August 2012). NBER Working Paper No. w18299.

Venkataramani, A., Martin, E., Vijayan, A., and Wellen, J. (2012) “The Impact of Tax Policies on Organ Donations in the United States”  American Journal of Transplantation 12 (8): 2133-2140

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