CMS Announces New Mandatory Program to Improve Kidney Transplant Accessibility

The Centers for Medicare & Medicaid Services (CMS) has unveiled the Increasing Organ Transplant Access (IOTA) Model, a proposed initiative aimed at transforming organ transplantation in the United States by:

  • Increasing organ donations and the number of transplants performed
  • Improving the efficiency and clinical quality of kidney transplant hospitals
  • Improving health equity and access

Roughly half of the transplant hospitals in the US will be impacted by this mandatory model and its requirements.

Set to begin January 1, 2025, this six-year mandatory program focuses on increasing the availability and efficiency of kidney transplants through performance-based payment incentives.

Learn more details about the proposed program and how it will impact transplant hospitals below.

IOTA Model Overview

The IOTA Model as proposed will be a mandatory model that begins on January 1, 2025, and ends December 31, 2030, consisting of six individual performance years. Selected hospitals will be required to participate.

The IOTA Model will provide incentives to participants to promote the following goals:

  • Maximize the use of deceased donor kidneys
  • Improve quality of care before, during and after kidney transplantation
  • Create greater equity in access to a kidney transplant by addressing social determinants of health and other barriers to care
  • Identify more living donors and assist potential donors through the donation process
  • Improve care coordination and patient-centeredness in the kidney transplant process.

The model will hold selected participants accountable through upside and downside performance-based payments and includes requirements to address health equity and transparency.

Hospital Eligibility

CMS has proposed to select half of the donation service areas (DSA) in the country. All eligible kidney transplant hospitals contained within the DSA would be required to participate in the model. CMS anticipates selected participants will total approximately 90 hospitals.

Non-participating hospitals will serve as the comparison group to evaluate the effectiveness of the model.

Eligibility for participation will include non-pediatric transplant hospitals with an active kidney transplant program that performed at least 11 or more kidney transplants during each of the prior three years—2022 to 2024—in addition to having at least 50% of the hospital’s annual transplants being furnished to non-pediatric patients.

Performance Score

The maximum performance score will be 100 points and is calculated on a set of proposed metrics in three distinct domains.

  • Achievement. Based on the total number of kidney transplants relative to a participant-specific target, for a total of 60 points.
  • Efficiency. Based on the organ offer acceptance rate ratio, for a total of 20 points.
  • Quality. Based on the CollaboRATE Shared Decision-Making Score, Colorectal Cancer Screening, Three-Item Care Transition Measure, and a Post-Transplant Composite Graft Survival Rate measure, for a total of 20 points.


Based on a final performance score at the end of each year, selected participants will fall into one of three categories:

Upside Risk Payment from CMS

A lump sum payment made by CMS after the end of each performance year (PY) if a participant has a final performance score of 60 or greater. The maximum positive payment per transplant performed will be $8,000.

Neutral Zone

With a final performance score between 40 and 60, participants will not receive either an upside risk payment or owe a downside risk payment to CMS.

Downside Risk Payment to CMS

For a final performance score of 40 or below, the participant will owe CMS a lump sum payment after the PY. The maximum negative payment per transplant will be $2,000.

To accommodate participants who are new to value-based payment models, CMS is proposing that upside risk payments begin in PY1, while downside risk payments begin in PY2. This means that for PY1, participants with a score above 60 will receive upside payments, while participants below 60 will receive neither upside nor downside payments.

Health Equity Strategy

CMS is proposing that each IOTA Model participant be required to submit a health equity plan beginning in PY2, with updates to their plan submitted annually thereafter. The health equity plan must identify health disparities within the participant’s attributed patient population and outline a course of action to address them.

CMS is also considering requiring each participant to collect and report patient-level health equity data to CMS, which may include conducting health related social needs screening for food security, housing, and transportation.

The model will include a health equity performance adjustment that will provide a 20% score increase in the Achievement domain for a transplant performed for a patient from a pre-defined, low-income population.

Next Steps

The IOTA Model is currently undergoing the rule-making process and is seeking public comment prior to a final rule being issued. As such, proposed requirements within this model may change. CMS anticipates that model participants will be notified of selection three months prior to the model start date, which is approximately October 1, 2024.

The proposed rule can be found at the federal register’s website here.

We’re Here to Help

To learn more about the upcoming IOTA Model and how your organization can thrive under this CMS initiative, contact your Moss Adams professional.

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