# Substack Bundle — Organ Procurement Under Federal Fire: How Cost-Plus Reimbursement, a 2020 Metric Rewrite, and the DCD Boom Turned Death Determination and Organ Allocation Into Healthcare's Next Compliance Fight

## How to use
1. Open your Substack draft.
2. If video.mp4 is included, drag it to the top as the header embed.
3. Drag audio_full.mp3 into the post — Substack converts it to a podcast block.
4. Paste the show notes below the audio block.
5. Publish — Substack delivers to your public podcast RSS feed.

## Files in this ZIP
- audio_part1.mp3 — Part I
- audio_part2.mp3 — Part II
- video.mp4 — short-form clip (argil_xthread_9_16)

## Episode title
Organ Procurement Under Federal Fire

## Preview / hook (top of post, free side)
The second organ procurement organization in American history was decertified this August. A federal review of 351 cases found at least 28 patients may not have been deceased when procurement began. Part I traces the machinery that produced that outcome: regional monopolies, cost-plus reimbursement, a 2020 metric rewrite that drove production without measuring near misses, and a clinical practice that went from 2% to nearly half the donor pool in 25 years. Free to read and listen.

## Above-paywall intro
Part I covers the setup: what happened in Kentucky, how donation after circulatory death became the modal procurement pathway, what the federal reviewers actually found in 351 case files, and how the 2020 performance scorecard created blind spots that ran undetected for five years. Part II is where the structural analysis lives. Three active regulatory dockets are moving simultaneously, out-of-sequence organ allocation has become a second compliance problem inside the same system, and the implications for operators, investors, and builders are specific and near-term.

## Paywall transition line
Part II is for paid subscribers.

## Paid CTA (after paywall)
Paid subscribers get the full analysis: how out-of-sequence allocation became a second scandal, what the January 2026 proposed rule actually changes versus what the press release says, and the specific second-order effects for transplant programs, health systems, data infrastructure companies, and investors. Subscribe below to unlock Part II and all future deep dives.

## Show notes
This episode covers the structural forces behind the Network for Hope decertification, the second in American history and the first real test of the federal government's willingness to use enforcement authority it has held for decades.

You will hear about the shift from donation after brain death to donation after circulatory death, which went from roughly two percent of deceased donors in 2000 to just under half in 2025. That shift was driven by advances in normothermic regional perfusion and machine perfusion, and it happened faster than the evidence base, or the regulatory infrastructure, could keep up with.

The episode also covers the economics of organ procurement organizations in detail. Cost-plus reimbursement, standard acquisition charges, and the absence of any financial signal for restraint all combine to concentrate institutional pressure on volume in ways that price signals in normal markets would moderate.

You will also hear about the 2020 Conditions for Coverage rule, which genuinely improved transplant rates but created a production-only scorecard that ran for five years during the fastest expansion of circulatory death donation on record. Part II, available for paid subscribers, picks up with out-of-sequence organ allocation, the three regulatory dockets moving simultaneously, and the specific implications for anyone operating near this space.
