New Payment Model Aims to Boost Transplant Access

Tackling inequity and transparency

Kidney transplant is widely accepted as the best treatment for kidney failure. Yet many of the 120,000 individuals diagnosed with kidney failure each year will never receive one. There are approximately 90,000 people on the deceased donor kidney transplant list. Still, only approximately 28,000 kidney transplants are performed each year in the United States, and 5000 people die on the waiting list each year, according to data from the national Organ Procurement & Transplantation Network (3).

Despite the dire need for kidney allografts, up to 30% of donor kidneys are unused each year because of system inefficiencies. Kevin Longino, MBA, chief executive officer of the National Kidney Foundation and a kidney transplant recipient, said in a statement that discarding a donor's kidney is a disservice to donors, their families, and people relying on dialysis who could benefit from a transplant (4). “It is fundamentally necessary to reform the transplant ecosystem to one that honors organ donors and their selfless, life-saving gifts,” Longino stated. “The IOTA model will also uphold the responsibility of organ procurement and transplant professionals to deliver high-quality care, resulting in better health outcomes that close disparities in access to the life-saving treatment of kidney transplantation that every [patient with kidney diseases] deserves.”

“It is fundamentally necessary to reform the transplant ecosystem to one that honors organ donors and their selfless, life-saving gifts.”

Longino also applauded the focus on increasing transparency. Patients on the waiting list and their nephrologists often receive little information about their status, whether they have been offered allografts that were turned down by their transplant team, and why.

“Nephrologists and their patients don't know where things stand sometimes,“ said Michelle Josephson, MD, FASN, transplant nephrologist at The University of Chicago, IL, and ASN past president. “It's been a black box, and this [model] will open that up.”

The model encourages transplant centers to have monthly shared decision-making discussions with waitlisted patients and to keep patients informed when an organ is offered to them and turned down, along with the reason behind the decision. Josephson said that patients are more engaged than ever, and the model will provide valuable information on how much and what type of information patients want. The model will also provide metrics on transplant centers’ organ acceptance rates, their transplant criteria, and more information about their waitlists, which may help patients select centers.

Additionally, the model acknowledges racial, ethnic, geographic, and socioeconomic disparities in those offered transplants. For example, patients with private insurance are more likely than those with public insurance to have a living donor transplant, according to the current CMMI plan. Furthermore, some transplant programs use social determinants of health, such as access to transportation or the ability to afford copays for posttransplant immunosuppression regimens, as criteria to determine transplant eligibility, which may contribute to disparities.

The IOTA model aims to address some of these problems. Its goals are to:

• Maximize the use of deceased donor kidneys

• Improve patient care before, during, and after transplant

• Increase transplant access equity by addressing barriers

• Identify more living donors

• Improve care coordination and patient-centeredness

Josephson believes that the randomization of centers in the model and the flexibility that centers will have in meeting the goals will help the field learn the best practices to reach these goals. “I’m very enthusiastic about the goals,” Josephson shared. “We’ll see what happens. Sometimes things work out better than you expect; sometimes you learn things you didn't expect or find out everything you thought was wrong.”

Incentivizing growth and efficiency

Previous payment models from the Centers for Medicare & Medicaid Services (CMS), like the 2021 End-Stage Renal Disease Treatment Choices model and the 2022 Kidney Care Choices model, incentivized nephrologists and dialysis centers to evaluate and refer patients for transplants. But that left a bottleneck at transplant centers that were not receiving incentives to expand transplant access, explained Sumit Mohan, MD, FASN, MPH, professor of medicine and epidemiology at Columbia University in New York City. “If [the transplant center] doesn't have the bandwidth to take the patient, evaluate, waitlist them, or [have them undergo a] transplant, then [the referring physician's] efforts were in vain,” he said.

The IOTA model's focus on incentivizing transplant centers to grow is “a massive change,” Mohan said. Participating hospitals will receive incentive payments if they reach yearly performance goals. Those that fail to meet their metrics have to pay CMS. Centers may also fall in a neutral performance range without an incentive or penalty. Centers that meet their metrics will receive an additional $8000 per Medicare fee-for-service (FFS) beneficiary who undergoes a transplant. Those that fail to meet goals must pay CMS $2000 per patient. The metrics include the number of adult kidney transplants performed regardless of the payor, the center's organ offer acceptance rate, graft survival, shared-decision making, colorectal cancer screening, and a three-item care transition metric.

Mallika Mendu, MD, MBA, FASN, a nephrologist and vice president of Clinical Operations and Care Continuum at Brigham and Women's Hospital in Boston, MA, said it is the first model focused on kidney transplants and helps align incentives for organ procurement organizations, transplant centers, and hospitals. She also said that the focus on increasing transplant volume was very positive. Mendu explained, “The more transplants [that transplant centers achieve], the more patients are going to live longer and healthier lives because the data [are] very clear that they are superior to dialysis from a clinical outcomes perspective and a quality-of-life perspective.”

Mohan said that incentivizing hospitals to improve their organ acceptance rate could help reduce the number of organs discarded and help make the allocation system more efficient. He explained that hospitals will have to provide a good reason for turning down a kidney. It will also encourage hospitals to add filters in the allocation system to ensure that their patients are offered only organs that they will consider or to temporarily inactivate a patient on the waitlist who is unable to receive a transplant at the moment because of a short-term illness or injury. “It allows the allocation system to become more efficient,” he said. “The organ gets to where it needs to go sooner and has a lower likelihood of being discarded.”

Josephson noted that the incentives may also help transplant surgeons learn more about making the most of the available allografts. “Not every kidney can be used, and we don't know what the sweet spot is,” Josephson said. “We may start to get a sense of how far we can go in using these organs and how to do it successfully.” Josephson also appreciated the focus on improving long-term transplant patient care. “The goal is for the [organs] to last,” she said.

The model also contains features geared to overcome socioeconomic hurdles that stand in the way of transplants for patients with limited income, those with public insurance, or other underserved groups with greater health disparities. Participating hospitals must have health equity plans that identify these populations and devise ways to serve them better. Centers will get extra credit toward their quality metrics for transplants in patients from populations with limited income. They will also receive incentives for providing transplants for patients who are dually eligible for Medicare and Medicaid or whose living donors qualify for the living donor assistance program. Medicare will also cover copays for transplant medications for eligible patients, so a lack of secondary insurance or an inability to afford copays will not stand in the way of a transplant.

Mendu said that including patients with lower incomes and those covered by Medicaid was very positive. But she noted that the model did not include adjustments for potentially greater care needs or higher rates of comorbidity in these populations, which could add to care costs and make it harder for centers caring for these patients to achieve targets. “Early monitoring of the success of the models and particularly the impact on patients from [populations of limited incomes], vulnerable populations, [and] Black and Hispanic patients is going to be critical to ensure [that] there aren't any unintended consequences of the model,” she said.

Room for improvement

Many experts praised the overall goals and design of the model but say there may also be room for improvement. “It's a good model,” Mohan said. “We could tweak some things and make things better.” Mohan noted that the growth goals are ambitious, with a target of 50% growth in the number of transplants. He said that might be doable for a hospital starting with 100 transplants per year but might be more challenging for hospitals already doing several hundred per year.

It is also unclear whether the incentive payments will be large enough to help support growth and improved care. Mohan explained that although the model measures a center's performance based on total transplants, it will only receive incentive payments for Medicare FFS patients. Patients covered by Medicare Advantage plans, who make up a growing share of those covered by Medicare, would not count. For example, a hospital that performs 200 transplants each year, half of which are FFS patients, would receive $800,000 in incentive payments if it meets its performance metrics. Mohan said the payments could help fund a patient outreach coordinator, social worker, or patient navigator but might not go much further and is contingent on reaching all of its metrics. Falling short on some metrics or having a larger proportion of Medicare Advantage patients would reduce its incentive payments.

Mendu agreed that $8000 might not be enough of an incentive. She suggested added incentives geared to increasing transplant access equity or providing upfront payments to help defray the associated care costs. Mohan and Mendu agreed that the model's success will be measured based on its impact on transplant volume and whether it boosts transplants among populations that are underserved. “The bottom line of what IOTA is doing is trying to grow transplant volume across the country,” Mohan said. “That will be a key measure of success.”

Mendu said that she hoped CMMI would use the data it collected from the pilot to improve the model over time. She also applauded CMS's recent focus on kidney care payment models. “I hope that CMS continues to really listen to the clinicians, patients, and patient advocates and really hear the feedback and be open to iterating over time,” she said.

At the time of publication, CMMI was seeking feedback on the proposed model and its timeline for implementation, and ASN and its committees were reviewing the plan and submitting feedback. “[CMMI is] being thoughtful and careful about how to do this,” Mohan expressed. “[It's] very clear about the goals and [wants] to get it right. That is really refreshing.”