In JAMA Surgery, Wall and colleagues¹ examine the financial impact of the new acuity circles policy for liver allocation enacted in early February 2020.¹ Their data from 2 liver transplant centers show an increase in cost of $7200 per accepted and $5600 per declined liver donor. Extrapolation over the 9700 liver donors across the United States in 2020² yields an increase of nearly $70 million to the US transplant system.

Two important points arise. The first is that acuity circles cost has not been meaningfully modeled by the United Network for Organ Sharing, and cost overall has not been part of the national discussion. Although some argue increased costs are justified, this is based on the flawed assumption that decreased waiting list deaths equate to lives saved.³ Terry Therneau, PhD, cochair of the Scientific Registry of Transplant Recipients Technical Advisory Committee pointed to this as creative bookkeeping and said that using lives saved rather than the more truthful deaths deferred until next year overestimates success and minimizes failures.⁴ In other words, you cannot save a life without a transplant. This is particularly concerning because many Scientific Registry of Transplant Recipients models predict acuity circles will decrease overall transplants. Although Scientific Registry of Transplant Recipients attributes this to a modeling defect, the facts are that between 2019 and 2020, whereas the total number of deceased donor transplants in the United States increased by 3%, liver transplants increased by only about 0.5%, associating acuity circles with a reduced increase in transplants.² Predictions that acuity circles will also decrease kidney transplants are concerning given the $1 million or more savings in dialysis costs per transplant per year.⁵