CMS Proposes Mandatory Kidney Care Model With Financial Risk For Hospitals

Dive Brief:

• The CMS is proposing a new mandatory Medicare payment model to test whether performance-based incentives for hospitals might improve the hodgepodge system connecting patients who need kidney transplants with viable organs.
• The six-year model announced Wednesday, called Increasing Organ Transplant Access, is meant to encourage transplant hospitals to use more available kidneys and facilitate more transplants from living donors, increasing access to organs for patients with end-stage renal disease while lowering Medicare spending. IOTA, if finalized, would require roughly a third of the nation’s organ transplant hospitals — 90 facilities in select donation service areas — to participate beginning in 2025.
• The model would measure hospital performance based on the number of kidney transplants, organ acceptance rates and quality of transplant care. Based on those metrics, hospitals would either receive bonus payments from the CMS — up to $8,000 per transplant — or be penalized for poor performance, up to $2,000 per transplant.

Dive Insight:

Research has shown that a kidney transplant improves survival rates and quality of life for the hundreds of thousands of Americans with end-stage renal disease compared to remaining on dialysis. Currently, almost 89,500 people are on the waiting list for a kidney. However, about a third of donor kidneys go unused each year, according to the CMS.

That’s because of significant problems with the U.S. organ transplant system, which has been plagued by inefficiencies, outdated technological infrastructure and monopoly control for decades.

A Senate Finance Committee investigation in 2022 found notable systemic failures, including improper organ screening and communication breakdowns, led to hundreds of people developing diseases from transplanted organs between 2007 and 2015. Seventy people died from those illnesses.

Much of those issues can be traced back to organ procurement organizations, or OPOs — nonprofits certified by the government to secure organs from deceased donors and connect them to living transplant candidates. A separate investigation by a House subcommittee in 2022 also found OPOs were failing to secure many viable organs, contributing to deaths.

According to government statistics, approximately 17 Americans die everyday waiting for an organ transplant.

However, OPOs have little external accountability, and for decades were allowed to calculate and report their own organ collection data, sparking a government crackdown in 2019.

Last fall, the controversy led President Joe Biden to sign a bill overhauling the system by breaking up the monopoly that allowed one nonprofit — the United Network for Organ Sharing, or UNOS — to serve as the sole contractor managing the organ procurement and distribution system.

Earlier this year, the government issued requests for proposals to divvy out contracts to multiple vendors, while the House Energy and Commerce Committee launched another investigation into UNOS to ensure implementation of the law.

Now, the CMS is proposing another bid to improve the beleaguered organ distribution system for patients with end-stage renal disease — especially for underserved Black and minority patients.

Along with providing upside and downrisk risk for providers to try and hold them better accountable for transplantation quality, IOTA includes a health equity performance adjustment giving hospitals more credit for transplants performed on low-income individuals.

Historically, tenets of the organ distribution system such as racially biased tests have led to Black kidney transplant candidates being pushed down the waiting list, exacerbating existing disparities. Black people in the U.S. are four times as likely to develop kidney failure as White people, but are much less likely to receive a kidney transplant.

IOTA would also provide flexibilities for hospitals that address social determinants of health barriers to care, like food insecurity, while requiring hospitals to create health equity plans.

The model is CMS’ latest targeting kidney care in the U.S. The agency’s innovation center launched the ESRD Treatment Choices Model in 2021 in a bid to increase access to kidney transplants and greater use of home dialysis. Similarly, the Kidney Care Choices Model launched in 2022 aims to better care coordination to improve outcomes for people with chronic kidney disease.

However, such models tested by the CMS have yielded a mixed bag of results. ESRD Treatment Choices, for example, failed to lower costs in its first year, but did increase the number of patients on the waitlist for transplants.