AHA cautions against mandatory organ transplant payment model

The American Hospital Association (AHA) has expressed key concerns with a newly proposed organ transplant payment model, causing the group to urge the CMS Innovation Center to not implement it.

The Innovation Center proposed the Increasing Organ Transplant Access (IOTA) Model in May 2024 when it announced the six-year mandatory program aimed at increasing kidney transplants. According to the Center’s website, the IOTA Model focuses on transplant hospitals using more kidneys that become available for transplantation and facilitates the transplants from living donors. The Model also encourages greater care coordination and patient-centered care while minimizing unnecessary spending.

However, the AHA said design features in the proposed IOTA Model are flawed, which would cause the model to “not meaningfully advance the move to value.”

“[W]e are concerned that many of the model design features may in fact exacerbate inequities and negatively impact patients’ quality of care,” the trade association wrote in a July 16th letter to CMS Administrator Chiquita Brooks-LaSure. “We are particularly concerned that the model’s heavy focus on transplant volume may incentivize unintended consequences, such as sub-par matches. Given the potential negative impact on patient outcomes, we urge CMMI to not implement the IOTA model at this time. As written, it is not fully developed and contains fundamental flaws.”

The letter stated that tying 60% of a hospital’s performance score to transplant volume would require hospitals to increase their historical volumes by 150% plus a national growth rate to achieve a maximum score. The performance incentive could encourage “sub-par organ matches.”

The AHA also argued that the IOTA Model, as it is proposed, would create “unnecessary disruption and uncertainty to the transplant ecosystem” as it already undergoes transformation. According to the letter, the ecosystem is already implementing the Organ Procurement and Transplantation Network (OPTN) Modernization Initiative and Securing the U.S. Organ Procurement and Transplantation Network Act, and adding a mandatory model would create even more workflow, staffing and reporting changes.

Additionally, the trade association expressed concerns about a lack of risk adjustment to incent healthier patient populations, which may add to existing inequities in kidney transplantation.

A major goal of the IOTA Model is to advance health equity, particularly for access to organ transplantations by race, ethnicity, disability and socio-economic status, according to the model’s webpage. The Innovation Center says there will be a health equity performance adjustment in the achievement domain to “give participating transplant hospitals more credit for a transplant performed for a person in a pre-defined, low-income population.”

However, AHA said the model has “built-in conflicting metrics by including measures such as offer-acceptance ratios and graft survival rates.”

“On the one hand, the model would heavily incentivize volume increases, but on the other, offer-acceptance ratios would incentivize more conservative selection of organs for transplants,” the letter stated. “The methodology for these other measures also differs from the standards and reporting requirements established by OPTN.”

The mandatory nature of the model and a start of January 1, 2025, are inappropriate, the letter added.

AHA urged the Innovation Center to reassess the IOTA Model following changes under the OPTN modernization initiative rather than implement it this coming year. Switching it to a voluntary program would also improve the model, the trade association said.

Public comments on the IOTA Model have closed. CMS has not indicated when it expects to finalize the model.