Nephrologists are weighing the effects of five years of federal value-based kidney care, a period marked by measurable shifts in how patients start dialysis and approach transplant. During the American Society of Nephrology (ASN) Kidney Week 2026 in Denver, experts discussed how shifting payment rules and the rapid growth of Medicare Advantage (MA) are prompting some practices to leave the programs.
The session “Value-Based Care in Nephrology: Slow Death or Lessons to Learn?” was moderated by Gaurav Jain, MD, FASN, a professor at the University of Alabama at Birmingham, and Mallika L. Mendu, MD, MBA, FASN, chief population health officer at Mass General Brigham. The discussion followed the end of the Kidney Care First (KCF) option under the Kidney Care Choices (KCC) model and adjustments to the Comprehensive Kidney Care Contracting (CKCC) option.
Kidney Care First enrollment drops sharply
Frank C. “Chip” Brosius, MD, a University of Arizona medicine professor who headed his institution’s KCF initiative, characterized the program as a practice-level choice. This option included utilization and quality metrics as well as financial rewards, but did not involve splitting savings or losses. Brosius cited CMS data indicating that enrollment dropped from 30 sites in 2022 and 2023 down to 15 in 2025. These participating groups represented around 6% of the total aligned beneficiaries.
Brosius identified the quality gateway as a primary driver for this decline. To avoid a 20% penalty, practices needed to complete two patient activation surveys and an annual depression screening for over half of their aligned patients within specific timeframes. He described this requirement as a significant burden on his team.
“This really was a huge load on our staff,” Brosius remarked. He advised merging these requirements into the overall quality score and enrolling high-risk stage 3 CKD patients in upcoming programs.
Varun Chawla, MD, MPH, a private nephrologist in the San Francisco Bay Area, reviewed the independent assessment of the 2023 CKCC model, which was in its second year. The review found that compared to similar patients, the model boosted optimal dialysis starts by 31% and home dialysis by 10%. While living donor transplant numbers rose by 22%, the overall transplant rate remained unchanged.
Medicare spending increased by $304.8 million, primarily due to incentive payments to participants. Chawla noted no changes in hospitalizations, readmissions, or ED visits. He highlighted structural issues with CMS’s method of resetting spending benchmarks annually through a retrospective trend adjustment.
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Medicare Advantage migration shakes kidney contracts
Since CKCC covers only traditional Medicare, patients who switch to Medicare Advantage (MA) are removed from the panel. The proportion of dialysis patients in MA climbed from roughly 25% in 2020 to about 52% by December 2023. CMS set a 50% reduction in CKD quarterly capitation payments for 2026, removed the transplant bonus, and added a 1% benchmark discount.
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 called for predictable benchmarks, a solution for MA migration, and cash flow to support care teams.
Syed Ali Husain, MD, MA, MPH, FASN, a transplant nephrologist at NYU Langone Health, examined the transplant-oriented Increasing Organ Transplant Access (IOTA) model. Previous models targeting referring nephrologists failed to improve transplant access because centers control waitlisting and organ offers. The mandatory IOTA model, which started July 1, 2025, applies to centers in roughly half of the country’s donation service areas.
New transplant model shows early promise
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. In the first nine months, the 97 participating centers included in an analysis Husain coauthored had a 5% increase in transplant volume. The 80 nonparticipating centers had a 3% decline.
Outpatient Dialysis Starts and Transplant Access
A study found that starting outpatient dialysis avoids hospitalization for about 60% of patients. This approach costs less, averaging $3178 per member per month over a year.
MA patients face transplant access hurdles
Transplant data show concerning trends for Medicare Advantage enrollees. One study found these patients were 13% less likely to be waitlisted. They were also 15% less likely to receive a living donor transplant once waitlisted. Another study indicated a 29% lower transplant rate for patients aged 18 to 74 years. Experts cite sparse data on acute care outcomes and acknowledge that direct comparisons are difficult.