Redesigning transplant and OPO center incentives (Chan and Roth in JAMA; Bae, Sweat, Melcher and Ashlagi in JAMA Surgery)

 

Chan A, Roth AE. Reimagining Transplant Center Incentives Beyond the CMS IOTA Model. JAMA. Published online January 26, 2026. doi:10.1001/jama.2025.26194 

 "On July 1, 2025, the Centers for Medicare & Medicaid Services (CMS) launched the Increasing Organ Transplant Access (IOTA) model, a national experiment in revising how transplant centers are evaluated and paid.

"For decades, transplant centers were primarily judged by 1-year graft and patient survival for patients who underwent a transplant. That standard, designed to safeguard quality, sometimes constrained access to transplants by rewarding risk avoidance rather than expansion. This contributed to persistent kidney shortages, alongside continued organ nonutilization.1

"The IOTA model marks a deliberate rebalancing. CMS is tying payment not primarily to short-term survival, but to 3 domains: achievement (60 points for transplant volume), efficiency (20 points for kidney offer acceptance), and quality (20 points for graft survival).

...

"A kidney transplant begins with an organ procurement organization (OPO). Yet OPOs remain outside the IOTA payment framework, perpetuating fragmentation between procurement and transplant.

"Recent experience with OPO performance metrics illustrates how narrow incentives can distort behavior. After CMS introduced tier-based OPO evaluations in 2021, lower-performing OPOs increased organ recovery, which also sharply increased discards, reliance on higher-risk organs, and out-of-sequence kidney placements,3 raising concerns about fairness to waitlisted patients.4 

...

"Emerging economic and experimental research suggests that joint accountability—rewarding procurement and transplant entities together for improving population health—can both shift recovery, discard, and transplant numbers and produce improved gains in patient health (Table).1 Without such system-level metrics spanning OPOs and transplant centers, IOTA will operate within a fragmented ecosystem where incentives push procurement and transplant in different, sometimes counterproductive, directions."

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See also

Bae H, Sweat KR, Melcher ML, Ashlagi I. Organ Procurement Following the Centers for Medicare and Medicaid Services Performance Evaluations. JAMA Surg. 2026;161(1):97–100. doi:10.1001/jamasurg.2025.5074