Assessing the Impact of Certificate of Need Laws on Organ Transplantation Outcomes

Abstract

This dissertation examines how institutional regulations and regional dynamics influence the availability and quality of organ transplantation services in the United States. The first chapter assesses the average effect of certificate-of-need (CON) regulations on transplant outcomes across five organs—heart, kidney, liver, lung, and pancreas—using center-level data from 2010 to 2023. Although CON regulations generally enhance availability, they are associated with lower average quality, particularly for heart and liver transplants, possibly due to expanded access for higher-risk patients. The second chapter employs a synthetic difference-in-differences approach to evaluate the effects of repealing and reinstating CON laws on kidney transplants in two states: New Hampshire and Indiana. The findings indicate significant changes in market share, while the changes in availability and quality are either modest or not statistically significant after policy changes. This suggests that the impact of CON regulations may be influenced by regional factors and the initial market conditions of each state. The third chapter investigates knowledge spillovers in heart transplantation using an instrumental variable approach. It finds that centers in regions with higher transplant activity benefit from shared expertise, improving patient selection and procedural efficiency. However, increased transplant rates may also coincide with lower average survival outcomes, likely due to the inclusion of more clinically complex patients. Collectively, these chapters contribute to the literature on healthcare regulation by providing empirical evidence on how policy design and regional specialization influence outcomes in high-stakes medical services. The findings highlight the importance of interpreting average outcome metrics in light of patient heterogeneity and institutional context and suggest that regulatory and regional collaboration strategies can play a critical role in improving transplant care.