Transplantation in Mandatory Kidney Payment Models: Understanding the Potential Influence of the ESRD Treatment Choices Model on the Increasing Organ Transplant Access Model - To the Editor

Sep 29, 2026

Uploaded by Sarah

Kidney transplantation improves survival and quality of life for eligible patients with kidney failure compared with dialysis. To increase transplantation, the Centers for Medicare and Medicaid Services implemented two mandatory kidney payment models: the end-stage renal disease treatment choices (ETC) model (2021-2025) and the increasing organ transplant access (IOTA) model (2025-2031). Over a brief 6-month overlap, investigators mapped overlap and non-overlap centers, geocoded participation, and assessed center- and patient-level characteristics across IOTA quality metric domains using statistical comparisons and geographic analyses.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages5

Reading Time13 min

AccessFree to download

Introduction

Payment models and study rationale

Methods

Center identification and grouping

Outcomes and statistical analysis

Geographic visualization and tools

Results

IOTA-eligible centers and overlap structure

Center-level and patient-level characteristics (Table 1)

Correspondence RESEARCH LETTER Transplantation in Mandatory Kidney Payment Models: Understanding the Potential Influence of the ESRD Treatment Choices Model on the Increasing Organ Transplant Access Model To the Editor: Kidney transplantation improves survival and quality of life for eligible patients with kidney failure, compared with dialysis. 1 However, in 2022, only 26,309 people in the United States received a kidney transplant, compared with 550,859 people receiving dialysis.2 , 3 The Centers for Medicare and Medicaid Services (CMS) hypothesized that improving provider incentives would increase kidney transplantation. Accordingly, CMS implemented 2 mandatory kidney payment models: the end-stage renal disease treatment choices (ETC) model (January 1, 2021 to December 31, 2025) and the increasing organ transplant access (IOTA) model (July 1, 2025 to June 30, 2031) .4 ETC randomized dialysis facilities within 30% of hospital referral regions to incentivize increasing kidney transplant waitlisting and living donor transplantation. IOTA randomized transplant centers within 50% of Donor Service Areas to incentives to increase kidney transplantation, organ offer acceptance, and graft survival.5 ETC and IOTA have synergistic transplant goals. For example, ETC dialysis facilities are incentivized to refer more patients to be waitlisted for a transplant, whereas IOTA centers are incentivized to perform a transplant for referred patients.4 Although ETC and IOTA overlap in time for only 6 months (July 2025 to December 2025), this overlap provides a rare opportunity to evaluate whether complementary payment incentives for transplantation can drive long-term changes in practice patterns in dialysis facilities and transplant centers. In this study, we identified these “overlap” centers and compared them to IOTA-only centers to inform future evaluations of IOTA. We identified IOTA transplant centers using CMSpublished lists.5 We then identified eligible control centers that were not randomized to IOTA using the June 2023 Scientific Registry of Transplant Recipients Program-Specific Reports.3 We geocoded and assigned transplant centers to ETC if they were located within ETC-participating hospital referral regions. We categorized transplant centers into 4 groups: ETC and IOTA, IOTA-only, ETC-only, and neither model. For all 4 groups, we compared center-level and patient characteristics relevant to IOTA’s 3 quality metric domains—achievement, efficiency, and quality—using χ2 and Kruskal-Wallis tests (see Item S1: Supplementary Methods) .5 We used data from the January 2025 Scientific Registry of Transplant Recipients Program-Specific Reports and Organ Procurement and Transplant Network. We used ArcGIS Pro 3.4 (ESRI) and Stata Version 17.0 for geographic visualizations and analyses. There were 187 IOTA-eligible transplant centers: 37 ETC and IOTA, 66 IOTA-only, 28 ETC-only, and 56 centers in neither model (see Fig 1) . Among these centers, 49,993 patients received a transplant between July 1, Figure 1. Map showing the overlap between the ETC and IOTA mandatory kidney payment models. Abbreviations: ETC, end-stage renal disease treatment choices model; IOTA, increasing organ transplant access model. ETC regions are shown in blue, IOTA regions in yellow, and ETC/IOTA overlap regions in green. Kidney Med Vol 8 | Iss 1 | January 2026 | 101177 1 Table 1. Center-level and patient-level Characteristics of IOTA-eligible Kidney Transplant Centers, Stratified by Means of Participation in the Mandatory ETC and IOTA Kidney Payment Models | Transplant Centers in | | Transplant Centers in | | | | | --- | --- | --- | --- | --- | --- | | Both IOTA, ETC | | the IOTA Intervention | Transplant Centers | Transplant Centers | | | Intervention Regions | | Region Only | in ETC-Only | in Neither Region | | | (ETC + IOTA) | | (IOTA-only) | (ETC-only) | (Neither) | | | (n = 37) | | (n = 66) | (n = 28) | (n = 56) | P value | | Tra

FAQs

What are the ETC and IOTA mandatory kidney payment models?

ETC (January 1, 2021 to December 31, 2025) and IOTA (July 1, 2025 to June 30, 2031) were designed to change incentives for dialysis facilities and transplant centers to increase kidney transplantation and related performance measures.

Why is the ETC and IOTA overlap period important to this study?

Because ETC and IOTA overlap for only 6 months (July 2025 to December 2025), the overlap centers create a rare opportunity to evaluate whether complementary payment incentives drive longer-term practice pattern changes.

How were transplant centers and control centers selected for comparison?

IOTA transplant centers were identified using CMS-published lists, while eligible control centers not randomized to IOTA were identified using June 2023 program-specific reports; centers were then assigned to ETC based on location within ETC-participating regions.

Sep 29, 2026

Uploaded by Sarah