Increasing transplant rates, boosting transparency for transplant candidates, and emphasizing the importance of long-term, post-transplant outcomes: these pillars of ASN’s transplant policy advocacy—and others—are now enshrined in a new model from the Centers for Medicare and Medicaid Innovation (CMMI), released today. 

The Increasing Organ Transplant Access (IOTA) model underwent numerous revisions following a public comment period this summer. ASN is pleased to see many of its key recommendations reflected in the final model, which will be mandatory for approximately 50 percent of kidney transplant programs nationwide (a complete list of selected programs is available on this webpage). The ASN Quality Committee and the ASN Transplant Workgroup are presently analyzing the nearly-600 page rule. Overall, it appears CMMI has simplified the program and aimed to make it easier for transplant centers to succeed than under the originally proposed design—top ASN recommendations. 

The model has sharpened its focus on increasing transplant rates as the primary aim of IOTA, while remaining relatively non-prescriptive as to how kidney transplant programs attain that growth. CMMI adopted a key ASN suggestion to increase the maximum upside payment participants may receive for success on a per-transplant basis, nearly doubling it from $8,000 to $15,000. This increase reflects a detailed analysis ASN provided detailing how case-mixes are likely to become more challenging as participants accept more medically complex patients who would benefit from kidney transplant as well as more complex yet still clinically appropriate donor kidneys. However, the maximum payment downside remained unchanged at $2,000. 

Several proposed quality measures that ASN had questioned the value of relative to their administrative burden or evidence base were also removed. This change also supports ASN’s recommendation to focus the quality components of the IOTA on assessing outcomes over many years, shifting emphasis somewhat from the current 90-day and 1-year outcomes metrics. 

As anticipated, the model start date was moved back to July 1, 2025, aligning with ASN’s suggestion to allow participants more time to prepare than the January 1, 2025 start date floated in the proposed rule. 

Several aspects of the proposed model ASN supported, such as a transparency component to retrospectively share organ offers that were declined on patients’ behalf but successfully transplanted in others, did not make it into the final rule. However, other important components ASN supported—such as transparency about each transplant center’s unique criteria for accepting a patient to the waitlist—remained as originally proposed. 

ASN also observes that this model continues the legacy of the 2019 Advancing American Kidney Health initiative. That Executive Order, which set the ambitious goal of increasing access to transplantation (and home dialysis) for 80 percent of incident patients with kidney failure and enshrined the mandatory ESRD Treatment Choices model for nephrologists and dialysis organizations, also aimed at increasing access to transplantation and home dialysis. The society is optimistic that IOTA will catalyze more access to kidney transplantation for people who would benefit and bring this ambitious goal to provide optimal care into reach. 

A more detailed analysis of IOTA and what it means for both transplant nephrologists and general nephrologists will follow.

Additional IOTA resources: 

• The complete final rule is available here: https://public-inspection.federalregister.gov/2024-27841.pdf 
• The list of kidney transplant programs selected for participation is available on this webpage (scroll to the bullet points at the bottom): https://www.cms.gov/priorities/innovation/innovation-models/iota 
• A CMMI Fact Sheet is available here: https://www.cms.gov/files/document/iota-model-fs.pdf 
• The CMMI Press Release is available here: https://www.cms.gov/newsroom/press-releases/biden-harris-administration-finalizes-new-model-improve-access-kidney-transplants