Nephrologists Weigh Wins, Losses From 5 Years of Value-Based Kidney Care

Five years into federal value-based kidney care, nephrologists said the models have measurably changed how patients start dialysis and move toward transplant. However, speakers at the American Society of Nephrology (ASN) Kidney Week 2026, held this week in Denver, Colorado, said shifting payment rules and rapid Medicare Advantage (MA) growth are prompting some practices to leave. Speakers also examined the transplant-focused Increasing Organ Transplant Access (IOTA) model and how MA plan design affects access to dialysis and transplant care.

The session, “Value-Based Care in Nephrology: Slow Death or Lessons to Learn?” was moderated by Gaurav Jain, MD, FASN, a professor of nephrology at the University of Alabama at Birmingham, and Mallika L. Mendu, MD, MBA, FASN, chief population health officer at Mass General Brigham. It came after CMS ended the Kidney Care First (KCF) option of its Kidney Care Choices (KCC) model 1 year early, at the end of 2025, and reduced payments in the Comprehensive Kidney Care Contracting (CKCC) option for 2026 while extending it through 2027.¹

Why Kidney Care First Ended Early

Frank C. “Chip” Brosius, MD, professor of medicine at the University of Arizona, who led the university’s KCF program, described KCF as the practice-level option of the model, with quality and utilization measures and incentives, but no shared savings or losses. KCF practices accounted for about 6% of aligned beneficiaries, and participation fell from 30 practices in 2022 and 2023 to 15 in 2025, according to CMS figures he presented.² Brosius pointed to the model’s quality gateway as a key reason. Practices had to complete 2 patient activation surveys and an annual depression screening for more than half of aligned beneficiaries within set windows or be placed in the lowest performance tier with a 20% penalty.

“This really was a huge load on our staff. Not saying it wasn’t worthwhile, but I think making it a true gateway was perhaps not the best idea,” he said. He recommended folding those measures into the total quality score and enrolling patients with high-risk stage 3 chronic kidney disease (CKD) in future models.

KCC Improved Quality but Raised Medicare Spending

Varun Chawla, MD, MPH, a nephrologist in private practice in the San Francisco Bay Area whose group took part in CKCC from 2022 until spring 2024, dug further into the independent evaluation of 2023, the model’s second year. Compared with matched patients, the KCC model increased optimal dialysis starts by 31% and home dialysis by 10% and raised living donor transplants by 22%, although overall transplant rates did not change.² Net Medicare spending rose by $304.8 million, mainly because of incentive payments to participants, and Chawla noted there was no change in hospitalizations, readmissions, or emergency department use.

Chawla said the larger problems were structural. CMS can reset the spending benchmark after the year ends through a retrospective trend adjustment.

“The thing that I want to emphasize is the utilization risk is our risk, and we should own it. But the forecast error should not be our risk, and we should not be penalized for it,” he said.

CKCC covers only traditional Medicare, so patients who switch to MA leave the panel. The share of patients receiving dialysis enrolled in MA rose from about 25% in 2020 to about 52% by December 2023.³

For 2026, CMS cut the CKD quarterly capitation payment by 50%, eliminated the kidney transplant bonus, and added 1% benchmark discounts.¹ An actuarial review by Wakely Consulting Group estimated that applying those rules to 2024 would have produced about $90 million in net savings for CMS while cutting payments to kidney contracting entities by about 40%, Chawla said.⁴ He called for predictable benchmarks, a solution for MA migration, and cash flow to support care teams.

IOTA Model Shows Early Gains in Transplant Volume

Syed Ali Husain, MD, MA, MPH, FASN, a transplant nephrologist at NYU Langone Health, said earlier models aimed at referring nephrologists did little for transplant access because transplant centers largely control waitlisting and organ offer acceptance. The mandatory IOTA model, which began July 1, 2025, instead applies to transplant centers in about half of the nation’s donation service areas, with the rest serving as a comparison group. Centers are scored on transplant volume, offer acceptance, and 1-year graft survival and can earn up to $15,000 per qualifying Medicare transplant or pay up to $2000 per transplant with traditional Medicare or MA.⁵

In the first 9 months, the 97 participating centers included in an analysis Husain coauthored had a 5% increase in transplant volume, whereas the 80 nonparticipating centers had a 3% decline.⁶ Husain, who disclosed that he works at a participating center, noted that the second performance year adds MA transplants to payment calculations and risk-adjusts the quality domain. Still, he said the model could go further.

“I think the big missing thing here is the downside penalty is just not severe enough,” Husain said. “They’re not going to have a huge change in behavior among centers that think they can’t improve unless there’s more negative dollars [on the line].”

Building the Case for 2-Sided Risk in Medicare Advantage

Timothy A. Pflederer, MD, FASN, chief medical officer of Evergreen Nephrology, a value-based kidney care company, noted that more than half of patients with kidney failure are now enrolled in MA. He cited a 2022 study in JAMA Network Open that linked 2-sided risk contracts in MA to 15.6% fewer avoidable hospitalizations compared with fee-for-service care, while upside-only contracts showed no difference.⁷ Under MA contracts, he added, nephrology practices are increasingly accountable for broader quality measures such as diabetes and blood pressure control.

“What’s more important to a patient is a smooth transition to dialysis, which means that I started dialysis without being hospitalized,” Pflederer said. He shared unpublished Evergreen data showing that 60% of patients started dialysis as outpatients without hospitalization, at an average cost of $3178 per member per month over 12 months, compared with $9829 for patients who started as inpatients before transitioning to outpatient care. He acknowledged that companies like his have not yet published enough outcomes data.

“I think we need to expect that to drive the best outcomes, we have to take on risk,” he said.

How MA Networks Shape Kidney Transplant Access

Jillian Caldwell, DO, MS, a nephrologist and health services researcher at Stanford University, said CMS loosened time-and-distance network adequacy standards for outpatient dialysis beginning in 2021.⁸ In a 2025 study of 7154 facilities she presented, the median facility was in network for 61% of local MA contracts compared with more than 65% for the 2 largest chains and 14% for independent not-for-profit facilities.⁹

Transplant data were less encouraging. One study she cited found that MA enrollees starting dialysis who were aged 65 to 80 years were 13% less likely to be waitlisted and, once waitlisted, 15% less likely to receive a living donor transplant,¹⁰ and another study found a 29% lower transplant rate among MA enrollees aged 18 to 74 years.¹¹ The only kidney-specific MA star rating measure is the annual kidney health evaluation for patients with diabetes, and an ASN Quality Committee review found that frailty and advanced illness exclusions may remove patients with kidney failure from 10 measures.¹² Acute care outcome data in MA remain sparse, she said.

“We know that MA plans often upcode, so direct comparisons, even when controlling for comorbidities, are challenging as well,” Caldwell said. “But ultimately, this calls attention to an evidence gap that we really need to close as a community.”

Evidence Gaps and the Next Kidney Model

Several figures presented, including Evergreen’s internal outcomes, have not been published in a peer-reviewed journal, and the Wakely estimates were industry-sponsored. The CMS evaluation covers only the model’s second year, and Chawla noted that the Medicare accountable care organization program took 5 years to show net savings.

Jain said participation left a lasting mark on his own program, which joined KCF alongside Brosius’ group. “I truly do believe that our culture changed when we did Kidney Care First as an organization,” Jain said. “We started paying more attention to care coordination and behavioral health and putting the pieces in place for our patients.”

Asked during the question-and-answer period whether a practice-level model would return, Mendu pointed to the recently released Kidney Care National Plan and to CMS Innovation Center sessions at the meeting as signs that another kidney model is coming. “I think forums like this...are really critical to learn from the experiences of KCF, CKCC, and what will inform the next iteration,” Mendu said. “All signals point to yes, there will be another version.”

Chawla framed the stakes for that next iteration. “Value-based care is the right destination. We just need a good financial model to get us there,” he said.

References

1. Kidney Care Choices Model performance year 2026 model update: quick reference. CMS. Updated May 28, 2025. Accessed October 23, 2026. https://www.cms.gov/kidney-care-choices-model-performance-year-2026-model-update-quick-reference

2. Kidney Care Choices (KCC) Model: evaluation findings for performance year 2023. CMS. Accessed October 23, 2026. https://www.cms.gov/priorities/innovation/data-and-reports/2026/kcc-2nd-annual-report-aag

3. Outpatient dialysis services. In: Report to the Congress: Medicare Payment Policy. Medicare Payment Advisory Commission; March 2025. Accessed October 23, 2026. https://medpac.gov/wp-content/uploads/2025/03/Mar25_Ch5_MedPAC_Report_To_Congress_SEC.pdf

4. Heywood B, Large A, Arsenault P, Arzaluz L. Kidney Care Choices Model Program Savings Experience. Wakely Consulting Group; May 28, 2026. Accessed October 23, 2026. https://accountableforhealth.org/wp-content/uploads/2026/06/CKCCModelReviewWakely.pdf

5. Overview fact sheet: Increasing Organ Transplant Access (IOTA) Model. CMS. Accessed October 23, 2026. https://www.cms.gov/priorities/innovation/files/iota-model-fs.pdf

6. Husain SA, Levan ML, Thakur M, et al. Early changes in kidney transplantation following implementation of the Increasing Organ Transplant Access model. Clin J Am Soc Nephrol. Published online September 18, 2026. doi:10.2215/CJN.0000001225

7. Gondi S, Li Y, Drzayich Antol D, Boudreau E, Shrank WH, Powers BW. Analysis of value-based payment and acute care use among Medicare Advantage beneficiaries. JAMA Netw Open. 2022;5(3):e222916. doi:10.1001/jamanetworkopen.2022.2916

8. Contract year 2021 Medicare Advantage and Part D final rule (CMS-4190-F1) fact sheet. CMS. May 22, 2020. Accessed October 23, 2026. https://www.cms.gov/newsroom/fact-sheets/contract-year-2021-medicare-advantage-and-part-d-final-rule-cms-4190-f1-fact-sheet

9. Oh EG, Brazier JF, Gadbois EA, et al. Dialysis facility participation in Medicare Advantage networks was highest for large dialysis organizations in 2021. Health Aff (Millwood). 2025;44(3):313-321. doi:10.1377/hlthaff.2024.01142

10.Adler JT, Kuk AE, Drewry KM, et al. Medicare Advantage and access to living donor kidney transplantation among older patients receiving dialysis. J Am Soc Nephrol. Published online August 5, 2026. doi:10.1681/ASN.0000001209

11. Shah AD, Dana BA, Brazier JF, et al. Medicare Advantage enrollment and access to kidney transplant after the 21st Century Cures Act. JAMA. 2026;336(15):1341-1349. doi:10.1001/jama.2026.14391

12. Le D, Ahearn L, Wilk AS, et al. Assessment of Medicare Advantage Stars measures: impact on kidney care quality and future opportunities. J Am Soc Nephrol. 2026;37(9):2065-2073. doi:10.1681/ASN.0000001200