number of patients added to the waiting list grows (see Table 1-3). Also, although the number of donors has increased steadily since 1988, it is not growing as quickly as the demand for organs (GAO, 1997). Roughly 4,000 Americans die each year (11 people per day) waiting for organs (UNOS, 1999). Organs are obtained for transplantation from less than 1 percent of U.S. deaths.

In an effort to increase donation rates, the federal government announced the National Organ and Tissue Donation Initiative in December 1997. As a part of the initiative, the Department of Health and Human Services (DHHS) issued a regulation requiring all Medicare-participating hospitals to refer all deaths and imminent deaths to organ procurement organizations (OPOs). The regulation went into effect in August 1998. In April 1999, DHHS announced a 5.6 percent increase in donation in 1998 (DHHS, 1999a).

OPOs are subject to certification and recertification by the federal Health Care Financing Administration (HCFA), which issues performance standards. These standards are designed to promote the efficiency of OPOs. HCFA also approves waivers that permit a hospital to have an arrangement with a different OPO than the one assigned to its area.

The current arrangement of 62 organ procurement organizations nationally evolved gradually, reflecting improvements in transplantation science, organ preservation, and other factors. Historically, the hospital in which the donor resided was responsible for locating a recipient. Thus the earliest days of solid