The finance committee will come to order. The last place anybody wants to hear about gross mismanagement and incompetence is in the business of saving lives. That is precisely at unfortunately with the finance committee needs to discuss today. This mornings hearing is an update on the investigation senator, grassley and i, along with senator young have been conducting for more than 2. 5 years. It examines a network of dozens of organizations with the demand to organ transplant and a group that oversees and coordinates them. The United Network for organ sharing. We have reviewed 100 thousand of their documents, totaling more than half a million pages. Before i get to specific findings, i want to frame what we have learned as simply as possible. Already Many Americans are dying needlessly becauseuno and many of the transplant organizations it oversees are failing and seem uninterested in improving. The existing alphabet soup of acronyms and organizations, i will start out with a bitter background. It was named the organ procurement and Transplantation Network. Someone needed to management that system for the whole country so the government thought to contract an organization to run it. Unos was the only bidder for that contract. The contract has come up for bid seven other times. Unos has won all seven. Todays network, unos is made up of nearly 400 members including 252 transplant centers and 57 regional organizations known as oregon oregon procurement organizations. A family city and a family city in hospital room, thinking about donating a loved ones organs is not have a choice of opos. Those are the important terms to remember here. When a kidney is donated in another state and these to get to another state, that is where the opos come in. As our investigation shows, unos is doing this job poorly. Three years errors are shockingly common. Between 2010 and 2020, more than 1100 errors were filed complaints were filed by a few and others. In a number of cases, opos failed to complete a number of tests for things like blood disease and more. He found one person died after being transplanted with lungs that were marked with the wrong blood type. Similar blood type errors have happened many times. Some had to have organs removed after transplant. Another person was told he would likely die within three years after an opo of supplied him with a heart of a person who died from a billing it tomorrow. Unos did not do any disciplinary action. In further, another patient contracted cancer and an opo sound the case for months. Between 2008 and 2015, 229 organ transplant patients received about organs and more than a quarter of them died. He found 53 complaints between 2010 and 2020, as well as evidence that this was just the tip of the iceberg. In some cases, couriers missed a flight. In others, the orchids were abandoned at airports and some were never picked up. Any of these failures reserve to billiards resulted in organs being discarded. It is reasonable to assume that many of these are going unreported. Organ transplant professionals repeatedly told the finance committee that the unos complaint process was a black hole. A complaint with in and unos went quiet. And vesta gave an disciplinary measures really amount to much more than a slap on the wrist. Only one time has unos recommended that an opo lose their certification. The bottom line is the failures we uncovered cost lives. Thousands of organs donated each year wind up discarded including one in four kidneys. According to federal data, roughly 6000 americans die every year while waiting for an organ transplant. This kind of mismanagement has a disproportionate impact on minority americans. Africanamericans for example have a greater need for kidney transplants than some other demographic groups. The center for medicare and Medicaid Services recently issued new statements for new standards for opo performance and more than a third are failing to meet them. They are failing to increase supply of lifesaving available for transplant. Another area of the committees investigation has examined the i. T. , Information Technology of unos to run the transplant network. The system is outdated, mismanaged, and insecure. Easing such decrepit data to run the transplant late network put Sensitive Data at risk and there is no solution in sight. In a report issued last year, titled lives are at stake, the u. S. Concluded that unos does not have the Technical Capability. If you looked at the data between unos and many of the day the nations opos, i would wager the vast majority are hardworking, good people doing their best to save lives. The glaring issues uncovered in our investigation stems from failures at the top. Leadership failures. Our investigation is ongoing and it is clear the system needs reforming. Youre going to continue investigating unos and opos and policies that need changing at the federal level. This is not a partisan effort. Everybody wants this system to work with as few errors as possible. I want to command centers grassley, cardin and young. The three of them have been working very closely with us. This is a thoroughly bipartisan interest. I want to thank senator grassley, and senator cardin and senator thune. We are going to have lots of members interested in this. I see senator warren as well and i want to think ever witnessed panel for joining the community the committee today. Today we want to discuss about the u. S. Organ procurement and Transplantation Network. And the Government Contractor overseeing this program, the United Network for organ sharing. In 1984, Congress Passed the National Organ transplant act, a bill cosponsored by the late senator warren hatch, a friend of mine and a former chairman of this committee. A few years later in 1998, the federal government contracted with the United Network for organ sharing to oversee the Transplantation Network. The network performs three critical functions on behalf of the federal government. Policymaking, technology delivery, and oversight of member compliance with its policies and its procedures. However, more than a decade now, government watchdogs and the media have questioned the advocacy of the networks oversight. That is because of multiple reports of fraud, waste, abuse, criminality, deadly Patient Safety, and failure to recover organs. Some have even observed the network is 15 times more likely to lose, damage or mishandle any organ in transit and a Passenger Airline losing its luggage. I have written about all these issues and more, going way back to 2005. Sadly, the federal government has only recently begun to take action. As a result, thousands of organs go to waste each year, resulting in lives lost, and billions of dollars wasted. This system is even worse for people of caller color who are less likely to get on the waitlist and less likely to find a match. At least amongst themselves, the Networks Senior leadership admits these facts. One officials response to these concerns was that this is just that real americans are dumb and should be moved somewhere else to obtain lifesaving treatment. Of course, that attitude is totally unacceptable. Now, a bit more about the investigation into the network. In february 2020, this committee sent a net a letter to the network, questing information and data on its oversight of the transplantation organization. We found that there is a huge variability in how well Organ Procurement Organizations, known as opo, are serving their communities. According to the senate for medicare and Medicaid Services, as many as 2257 opos are feeling outcome and performance metrics. This variability has negative consequences for the Transplantation Network and causes transplant hospitals to have fewer organs from patients on the waitlist. We also found that the network has broken governments systems that fail to hold the members accountable for reoccurring Patient Safety issues. As i said, once again, when i started looking into this in 2006, network acts like the fox guarding the chicken house. Instead of a trustworthy and independent oversight body that holds its members accountable. As such, transportation failures , abo blood type testing, and allocation errors are common occurrences at underperforming opos. Mr. Chairman, it is about time into very timely that we hold the steering. Congress has waited too long to fix a broken system. We must sit insist upon accountability moving forward. S patients lives are at stake. Thank you very much senator grassley. As noted in my statement, im very glad we had senator young here as well. Senator young, senator grassley and senator cardin and myself have been at this for a long time. The committee has made a number of important findings during this inquiry. We believe it is in the publics best and truest to see these results. I ask our committee to submit all this memo and all documents in this memo to be submitted into the record. Let me introduce our guests. Mr. Sheppard is the chief executive officer of the unos. His Organization Currently holds the government contract for organ procurement and Transplantation Network. He has been in this role since 2012. Prior to joining unos, he served 15 years with the virginia government. The ceo for the Organ Procurement Organization located in st. Louis, missouri is also here. She turned her career as an organ procurement coordinator. In 2016, became the president and ceo overseeing the organizations operations including partnership for more than 120 hospitals and transplant centers located throughout missouri, arkansas, and Southern Illinois. This is a position he has held since january 2020. He began his civilian career in organ transportation in icu. I was a staff nurse in st. Louis, missouri in 1985 and has over 30 Years Experience in the transplant community. The transplant centers around the country and is also had a distinguished military career. Calvin henry is on the Patient Affairs committee in 2012. He received a double transplant in the hospital after being diagnosed with an untreatable lung disease considered to be a terminal illness. He was a successful Lung Transplant recipient and runs marathons. Mr. Henry has a professional background in Health Information and also volunteered as a patient mentor for a local transplant center in georgia. He connects those on the transport list with educational resources. Mr. Henry is urging immediate reforms in the transfer system that he entered into the records. Before he begins the statement, i ask for unanimous consent to do so. Dr. Jamie locke is at the university of alabama birmingham where she is a professor in the chief of the division of transplantation among other positions. She graduated from Duke University and completed her medical degree at Carolina University and her surgical residency at johns hopkins. We want to thank all our guest for their participation and we will begin with mr. Brian sheppard. Thank you mr. Chairman and members of the committee. Thank you for inviting me to discuss our organ by nation and transplant system and the role of the unos and our communitys ongoing efforts to increase transplantation. My name is Brian Sheppard and i am the ceo of unos, the nonprofit which holds the federal contract to serve as the working donation and transplant network. I have seen up close the power of Organ Donation and transplant, the thing and sustaining the families of organ donors and restoring the fire into transplant recipients. Unos worked with transplant hospitals, opos and patients to address the most important issues and we leverage experts in the field to continually improve the National System. Convene a community of diverse professionals and patients, sometimes with very strongly held opinions and leverage the diversity of opinions into a system that provides the rate as possible benefit to patients within transplant. All of the individuals on this panel with me have served on or lead at least one committee and two of them have served on the board of directors. Their opinions and insights have helped shape the system we have today. I look forward to having a conversation about that system. A system that just to mark its ninth consecutive record saving year of transplants and surpassed 41,000 transplants in 2021. A total never before received in a single year by the u. S. Or any other country. Transplantation on that scale would have been hard to imagine in 1984 when Congress Passed the National Organ transplant act. It has been an honor to serve the nation for over three decades. He also realized that unos is not the final word in Organ Donation. We are part of an multifaceted agency that includes multiple federal agencies and important roles for the cdc, the fda and nih and more. Consistent with the medical recommendations and best practices in health care quality, the opt and creates a role of peer monitoring and Quality Improvement. It complements but is different from the regulatory certification and oversight role rented to cmf to support their role. Unos is bounded by the optn contract and focus on those on developing equitable policy, and offering matters to patients through safe and secure modern technology and continuing to improve performance through peer review. Our work is closely overseen by herself Service Members on all our board of directors. That is a community that unos is so proud to be a part of. We have made rapid and remarkable changes in the past few years alone changes that have expanded equitable access. Increase priorities for the sickest nations, reduce disparities between races, ethnicities and geographies but there is always more to do. Are over 100 thousand americans waiting for an organ as we speak. Even as a 115 patients are successfully transplanted every day, another 17 die waiting. We cannot rest until every patient who needs a transplant is able to get one. By building on the success of our National System and ongoing efforts, we can get around that vision and when we do, our work saves life. They are prepared to work with any legislator to provide information or serve as a resource. If you again for inviting me to discuss the status of transplant and donation and i look forward to taking actions. Thank you mr. Shepherd. Misses mrs. Brockmeyer. I am the ceo of transplant serving missouri, Southern Illinois and eastern arkansas. At our organization, we followed the ethers of every donor, every time. Our team is committed to giving donors and their family they care they deserve while stewarding their gifts to patients desperately need. We depend on the broader National Transplant system as administered by unos to accomplish this work and need to urgently address Patient Safety. Each organ loss has a consequence to the thousands of patients waiting for a transplant. Furthermore, a discarded organ fails to honor the heroic gift from a selfless donor and compounds the family sense of loss. Unos lacks urgency and accountability around identifying and remediating the criminal loss of organs and are not required to publicly report adverse events when patients are harmed, organs are lost or the quality of patient care is deemed unsafe. Unos does not require clinical training, licensure or certification standards for opo delivered critical patient care. In this environment, who is looking out for the patient . Was being held accountable for patient care . No opo has actually ever been decertified regardless of its performance or safety record. Unos has failed to align its efforts to ensure Patient Safety and this has created tragic and deadly consequences. You must update our Technology System there. As opos, we are required to work with unos Donor Network every day. Donor net is slow to use and is hard to function when every minute counts. Opo transplant center staff are not empowered with the right information when time is critical. I have served in leadership roles on the opo committee and Committee Members and Industry Leaders voice repeated request to improve donor net. The consistent response was unos i. T. Did not have the bandwidth. The limitation of the unos Technology Eyes delaying and denying transplant to patients dying on the waitlist. Poor Technology Impacts the disturbingly high katie discard rate in the u. S. Are one in four kidneys never makes it to a patient for transplantation. Critical time is lost due to the inefficiency of donor net. Of course, an available organ should be offered to a patient in list sequence but far too much of the matching, particularly on older donors and orders are typically hard to place, are less due to the individual opos and transplant centers to find each other. Midamerican transplants have identified surgeons who have excepted kidneys that have been repeatedly turned down. These are life saving options for those patients. In may 20