Increasing Organ Transplant Access (IOTA) Model

The proposed Increasing Organ Transplant Access Model aims to increase access to life-saving transplants for patients living with kidney disease and reduce Medicare expenditures. This model would focus on encouraging transplant hospitals to use more of the kidneys that become available for transplantation and facilitate more transplants from living donors. Additionally, the model is designed to support greater care coordination, improved patient-centeredness in the process of being waitlisted for and receiving a kidney transplant, and more equitable access to kidney transplants. Through the model payments and policies, CMS aims to increase the care delivery capabilities and efficiency of kidney transplant hospitals selected for participation, with the goal of improving quality of care while reducing unnecessary spending.

The Increasing Organ Transplant Access Model is a proposed six-year, mandatory model that would begin on January 1, 2025. Visit the Federal Register to access the Notice of Proposed Rulemaking for the model. The comment period closes July 16, 2024.


  • Kidney transplantation is the best treatment for most patients with chronic kidney disease and end-stage renal disease, but there are more people in need of a kidney than there are organs available. Many people die while waiting for a kidney transplant.
  • Around 90,000 people were on the waitlist for a kidney transplant in the U.S. in 2023, but only about 28,000 kidney transplants were performed during that same time period, according to the Organ Procurement and Transplantation Network.
  • The Increasing Organ Transplant Access Model aims to increase the number of people who receive kidney transplants while improving their quality of care and the patient-centeredness of the kidney transplant process. 
  • The goal of the proposed model is to drive meaningful growth in the kidney transplant rate by maximizing the use of deceased donor kidneys and facilitating more transplants from living donors. 


Chronic kidney disease (CKD) affects nearly 15% of adults and is a leading cause of death in the United States. Approximately 130,000 Americans are diagnosed with end-stage renal disease (ESRD) each year, the most advanced form of CKD. Kidney transplantation is the best treatment for many people with kidney failure; however, there are far fewer donor kidneys available than people who need them, and approximately 5,000 people die each year while waiting for a kidney transplant.

The model would build on previous efforts by the Centers for Medicare & Medicaid Services (CMS) to improve care for patients living with kidney disease by addressing access to kidney transplantation, which is an important aspect of the care continuum for patients living with ESRD. The ESRD Treatment Choices (ETC) Model, launched in 2021, focuses on improving quality of life with greater use of home dialysis and increased access to kidney transplantation. The Kidney Care Choices (KCC) Model, launched in 2022, builds on the structure established by the Comprehensive ESRD Care (CEC) Model and aims to delay the need for dialysis for people with chronic kidney disease by improving the coordination and quality of care. 

Chronic Kidney Disease (CKD) Infographic - how the CMS Innovation Center is Supporting Care for CKD

The Increasing Organ Transplant Access Model is part of a wider effort by the Department of Health and Human Services’ Organ Transplant Affinity Group (OTAG), a collaborative effort by the Centers for Medicare & Medicaid Services (CMS) and the Health Resources & Services Administration (HRSA), to increase equitable access to organ transplants, improve accountability for the U.S. organ transplantation system, and increase the availability and use of donated organs.

Model Overview

IOTA Model Infographic sharing Model goals and statistics on KCD

The Increasing Organ Transplant Access Model — also referred to as the IOTA Model — is a proposed mandatory model that aims to increase the number of kidney transplants, increase equitable access to a kidney transplant, and improve the efficiency and capabilities of participating transplant hospitals.

The model would provide incentives for transplant hospitals 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 living donors through the donation process.
  • Improve care coordination and patient-centeredness in the kidney transplant process.

A participating transplant hospital would receive upside risk payments from CMS, fall in a neutral zone in which the hospital neither receives an upside risk payment nor owes a downside risk payment, or owe downside risk payments to CMS, based on the participating transplant hospital’s final performance score. The final performance score would be out of 100 points and calculated on a set of proposed metrics in three domains: 

  • Achievement: based on the number of kidney transplants 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.

Health Equity Strategy

Access to organ transplantation can vary by factors such as race, ethnicity, disability, and socio-economic status. Transplants, particularly living donor transplants, are much more common for people with private insurance. The model would include health equity incentives in the form of a health equity performance adjustment in the achievement domain. This adjustment would give participating transplant hospitals more credit for a transplant performed for a person in a pre-defined, low-income population. By adding focus on specific populations that are currently less likely to receive a transplant, the model would aim to give patients living with ESRD equitable access to the opportunity for live-saving transplants.

The model also would provide flexibilities for transplant hospitals selected to participate in addressing barriers related to social drivers of health — such as food insecurity — and require participating transplant hospitals to establish health equity plans to identify gaps in access.

Model Participation

Under the proposed Increasing Organ Transplant Access Model, CMS would select half of the donation service areas (DSAs) and all eligible kidney transplant hospitals there within to participate in the mandatory model. The other half of transplant hospitals would serve as the comparison group for evaluation purposes. Eligible hospitals would be non-pediatric transplant hospitals with an active kidney transplant program that perform an annual average of 11 or more kidney transplants in the three baseline years before the start of the model in 2025. The model would include data-sharing requirements and incentives for participating transplant hospitals to improve the patient experience. 

Individuals would receive a notice of attribution if their transplant hospital is participating in the model. In addition, individuals would retain their freedom of choice to seek care from any Medicare provider and would not be limited to their attributed transplant hospital.

Additional Information


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