The donor gives for free. Everyone downstream gets paid. That is the uncomfortable shape of the US organ and tissue economy, and you can see it in the public filings. The organizations that recover organs are nonprofits — but the largest report well over $100 million in annual revenue and seven-figure executive pay, inside a federal reimbursement model with no competition and, for decades, no enforced performance check. This is a follow-the-money account, built entirely from public records assembled in OrganWatch. It reports money by organization and role — never a person, never a donor.
A cost-plus monopoly
Each of the ~56 Organ Procurement Organizations is a federally designated regional monopoly: no two compete for the same territory. They are reimbursed by Medicare on a cost basis (42 CFR Part 413), with “organ acquisition costs” passed through to transplant hospitals and ultimately to CMS. The largest are not small charities: by their own IRS Form 990 filings, OneLegacy (Los Angeles) reported roughly $142.8M in FY2024 revenue with the CEO role compensated about $1.01M; the Philadelphia OPO reported about $152.9M; and the New York OPO's top officer role was reported at roughly $1.55M. The structural concern the Senate Finance Committee's bipartisan investigation documented is that OPO self-reported performance data was effectively unverifiable — a cost-plus, non-competitive monopoly whose regulator did not, for years, enforce the outcome metrics in statute.
The contract that ran on auto-pilot
One tier up, the national matching network (the OPTN, mandated by the 1984 NOTA) was run by a single contractor for roughly 36 years on near-automatic renewals. The OPTN contract runs on the order of $64M a year, funded largely by fees the transplant programs it oversees must pay it. Only with HRSA's modernization did it open to competition — with awards reported up to $235M to a new technology contractor. For most of its history, the body policing the system answered to essentially no competitive pressure.
The incentive that points the wrong way
Here is the finding that should stop a reader. In its bipartisan work the Senate Finance Committee stated that OPOs have greater financial incentives to focus on tissue recovery than on recovering lifesaving organs. Tissue — bone, skin, tendon, corneas — feeds a large processing market; organs do not pay the same way. The investigation also documented an roughly 850% rise in pancreata recovered “for research,” a category that can be counted toward performance without the same verification. When the money favors tissue over the organ that saves a life, the system's incentives are inverted from its stated mission.
From free donation to for-profit product
The tissue itself moves from gift to commerce. One nonprofit tissue foundation in this record runs an allograft operation reporting around $509.5M in revenue; a university tissue bank spun out a for-profit processor that became a publicly traded company. The donor consented to a donation; what follows is a manufacturing-and-sales business with processing fees, markups, and shareholders — the “nonprofit” recovery and the for-profit product often linked through related corporate entities.
Lobbying the referee, and the audits
When reform came, the industry spent to slow it: OPO-sector lobbying exceeded $450,000 in the first half of 2020 alone — a roughly 500% jump — with UNOS and the OPO trade association lobbying around the CMS rule and OPTN changes. And the spending that drew federal auditors' eyes is telling: HHS-OIG found one OPO had charged Medicare for ~$531,000 in unallowable or unsupported costs — including football tickets, parade-float expenses, and lobbying — with a separate nationwide audit flagging roughly $664,000 in improper education overhead. Public money, reimbursed at cost, spent on perks and on lobbying against oversight.
What this record is
Every figure here is institution- or role-level and source-linked in OrganWatch's follow-the-money section: revenue and compensation from public IRS Form 990 filings, contracts from USAspending, lobbying from Senate disclosures, findings from HHS-OIG and the Senate Finance Committee. It names organizations, roles, and dollar amounts — never an individual, never a donor or patient. The accountability is about how public money flows through a monopoly, not about the people it employs or the people it recovers from.
Companion: How Organs Are Taken From the Dying — the procurement-vs-care boundary and the HRSA findings.
The data: OrganWatch — the source-linked map, including 90+ follow-the-money findings with figures and citations.
Related: The US Organ System in the Government's Own Records and Used Without Consent — the oversight record and the consent gap that complete the picture.