Study shows that the organ transplant system favors the rich by allowing listings at multiple donor transplant centers.

A policy that allows people to register at multiple organ donor transplant centers appears to benefit the wealthiest patients rather than the sickest, according to a recent study.

Allowing people to register at multiple transplant centers throughout the United States was originally intended to give people who live in rural areas or at great distances from hospitals that specialize in transplant operations an equal shot at available donor organs. But the new study indicates that those who can afford to register as recipients in several centers are more likely to get a donor organ sooner than patients with greater medical need who register with only one.

The study, led by Dr. Raymond Givens, Ph.D., an advanced heart failure and transplant fellow at Columbia University Medical Center in New York, also uncovered that patients listed at multiple sites are more likely to have private insurance. Wealthier people were less likely to die while waiting for a donor organ.

“Multiple-listed patients, despite being less sick, were more likely to receive a transplant,” Givens said.

Read More: Are Public Appeals for Organ Donations Ethical? »

The report analyzed the data of 686,000 patients listed on the United Network for Organ Sharing (UNOS) database, which manages the national organ transplant database for the entire United States, including Puerto Rico.

The study looked at adult patients from 2000 to 2013 who were categorized as first time, single-organ candidates for heart, lung, kidney, or liver transplants.

In order to be listed in the UNOS database, patients must register with an organ transplant center. The agency encourages and allows patients to list at multiple sites because wait times for organ transplants vary depending on location.

“The whole idea behind multiple listing was intended to give people who live within geographic inequities a way to level the playing field,” Givens said. “The report raises the issue of fairness and certainly calls for a reexamination of the policy.”

Read More: The Organs in Our Body May Age Differently »

There are 11 transplant regions throughout the United States, according to the UNOS website. The number of transplant facilities differs in each region and from state to state. California has 22, Illinois has 9, and West Virginia has 1. Alaska, Idaho, Montana, and Wyoming don’t have any facilities.

The first step to get on the UNOS database starts at an organ transplant center. Patients must endure a thorough battery of tests to determine overall health and transplant feasibility.

The examinations are conducted by the team of doctors who work at the transplant site. Patients who want to list at multiple facilities must travel to each location for consideration.

The report attributes the higher rate of transplant to wealthy patients to the fact that richer people can afford transportation, lodging, and other costs associated with listing at multiple sites around the country.

Patients with state-run medical insurance tend to have lower incomes and less means to list themselves at numerous sites.

This is not the first time the multiple listing policy has been called into question, according to Dr. David Klassen, UNOS chief medical officer.

“It’s been controversial for years and quite political,” he told Healthline.

He added that the agency continues to evaluate the process for organ donor transplants.

“We are interested in addressing the root cause of geographic disparity and ways to make multiple listing unnecessary,” he said.

Read More: Stem Cell Transplants Offer MS Treatment That Reverses Disability »

But finding a solution that can tackle the issue of regional inequity won’t come easy.

According to Klassen, UNOS teams already use complex algorithms to determine who gets what organ and why. Among the things they take into account are regional wait times and the number of patients on the transplant list.

Equally important is the very nature of the organs in question. Not all organs behave the same once they are deemed ready for transplant.

Outside of the body, heart and lung can only survive between four to six hours, while the liver and kidney can endure for up to 10 and 20 hours, respectively. This also affects distribution.

A breakdown of the report shows that within a 13-year period, 2 percent of the nearly 34,000 patients waiting for a heart transplant were multi-listed, compared to 12 percent of the nearly 224,000 patients waiting for kidney transplant. About 3 percent of the nearly 25,000 patients waiting for lung transplant were multi-listed, while 6 percent of the approximately 104,000 liver transplants were multi-listed.

While no plan is in place to overhaul the entire system, UNOS is currently assessing the liver distribution algorithm, but it’s “still very much a work in progress,” Klassen said. The organization held two public forums in the past 15 months that he said were well attended.

“The liver community is revising the ideas [discussed at the forums] and attempting to come up with a way to revise and address geographic disparity,” he said.

Kellen and Givens both agree that the real issue at hand is supply and demand. There simply aren’t enough organs for people to receive transplants.

The UNOS web site shows that, to date, 122,572 people needed a lifesaving organ transplant, yet only 20,704 transplants have been performed as of August 2015, which are the latest statistics available.

“It’s the scarcity of organs that breeds the competition,” Givens said. “We need more people to be organ donors.”

Givens also points out that the study didn’t answer one other important question. Do multi-listed patients harm the transplant rates of single listed patients?

“I don’t have the answer to that yet,” he said. “That’s going to take a more sophisticated approach. I’m looking to answer that question and think it will be a very helpful part of the puzzle.”