The IOTA Model Is Here — But Dialysis Centers Are Still Missing the Patients Who Need It Most

Ninety thousand Americans are on the kidney transplant waitlist right now. Thirteen of them will die today. Not because there are no kidneys. Not because transplant surgery isn't available. But because the system designed to move people from dialysis to transplant is broken at a level most policy interventions never reach.

In July 2025, CMS launched the IOTA Model — the Increasing Organ Transplant Access Model — with the explicit goal of improving transplant rates among ESRD patients. It's a serious policy effort. It's the right instinct. And it solves roughly half the problem.

The other half? That lives upstream, at the dialysis center, where the referral pipeline either starts or quietly dies — and where IOTA doesn't reach.

What the IOTA Model Gets Right

The IOTA Model targets transplant centers — the hospitals and programs that actually perform kidney transplants. Under IOTA, transplant centers are financially incentivized to increase their transplant rates and penalized when performance falls below benchmarks. CMS designed this to create a market signal: improve access, move patients more efficiently through evaluation, and get more people transplanted.

This is meaningful. Transplant centers have historically operated with significant variation in how aggressively they recruit and evaluate candidates. Some centers are extraordinarily active. Others are passive, waiting for referrals to arrive rather than cultivating them. IOTA changes the financial calculus — it rewards centers that work harder to transplant more eligible patients.

For the patients who make it to a transplant center's door, IOTA creates real incentive for the institution to act. That matters.

The model also includes equity provisions, with particular attention to disparities in transplant rates by race, income, and geography. CMS has been explicit that IOTA is partly about closing gaps, not just improving aggregate numbers.

So far, so good.

What IOTA Still Misses

Here is the structural problem that IOTA does not address: the majority of ESRD patients never get referred to a transplant center in the first place.

According to data from the Journal of the American Society of Nephrology, only about 20% of dialysis patients are ever formally evaluated for kidney transplantation. The other 80% remain on dialysis — often for years, sometimes for the rest of their lives — without ever having their transplant eligibility assessed.

This is not primarily a transplant center problem. It is a dialysis center problem. And more specifically, it is a dialysis social worker bandwidth problem.

Dialysis social workers carry caseloads of 80 to 120 patients. They are responsible for mandatory SDOH screening under CMS requirements, care plan documentation, insurance authorization issues, housing crises, family emergencies, and discharge coordination. Their days are not slow. Their documentation burden is not small. ESRD is a life-altering condition that touches every dimension of a patient's existence — and the social worker is often the only person in the dialysis unit who is trained to address those dimensions holistically.

Transplant referral, done properly, is not a checkbox. It requires eligibility assessment, patient education about what transplant evaluation involves, family readiness conversations, coordination with the nephrology team, documentation, and follow-up. For a patient with significant SDOH barriers — housing instability, limited health literacy, no reliable transportation, a caregiver situation that isn't in place — that process can take weeks of active navigation.

Multiplied across an 80-patient caseload, it simply doesn't happen. Not because social workers don't care. Not because nephrologists don't know the data. But because the system was never designed to make it systematically possible.

IOTA reaches in from the transplant center end. The referral gap lives at the dialysis end. Those are two different problems, and right now, only one of them has a federal model behind it.

The Patients Who Get Left Behind

The 80% of dialysis patients who never reach transplant evaluation are not randomly distributed. They are disproportionately Black patients, rural patients, patients living in poverty, patients with unstable housing, and patients whose English is not their primary language.

We know this from the data. UNOS has documented persistent racial disparities in transplant access for decades. Black patients are less likely to be referred, less likely to be placed on the waitlist, and — after controlling for health factors — less likely to receive a transplant than white patients with comparable ESRD profiles. Rural patients face a compounding disadvantage: geographic distance from transplant centers, thinner dialysis social work coverage, and less access to the specialists who perform pre-transplant evaluations.

A patient transplanted with a living donor kidney lives, on average, 10 to 15 years longer than a patient who remains on dialysis — a difference documented in the New England Journal of Medicine. That gap in survival is the gap between being referred and not being referred.

The patients least likely to be referred are the patients who would benefit most from the intervention.

IOTA creates financial incentives for transplant centers to transplant more patients. It does not create infrastructure for dialysis social workers to identify, screen, and refer those patients in the first place. If the referral doesn't happen, the IOTA incentive never gets triggered.

The Social Determinants Problem Is Upstream, Not Downstream

There's another dimension here that the policy conversation tends to flatten: SDOH barriers are concentrated at the dialysis level, not the transplant level.

A patient who reaches a transplant center for formal evaluation has already cleared enormous hurdles. They have a nephrologist who flagged them. They have a dialysis social worker who followed through. They have enough stability in their life — housing, transportation, support system — to actually show up for the evaluation appointment.

The patients who don't get referred are often the ones for whom SDOH barriers are most acute. Unstable housing is one of the most commonly cited reasons for transplant evaluation delays, according to published nephrology literature. Lack of caregiver support — a requirement in most transplant protocols — is another. These are not medical barriers. They are social barriers. And they are best addressed at the dialysis center level, before the referral ever happens, by social workers who know the patient's whole situation.

This is precisely the kind of upstream intervention that CMS payment models have historically underinvested in. IOTA is a downstream solution to what is partly an upstream social work problem.

What Has to Change Next

The good news is that the architecture for upstream intervention already exists. Dialysis social workers are already in the room. CMS already mandates SDOH screening at dialysis centers. The data on ESRD patients is already being collected. What's missing is a systematic way to connect that data to transplant eligibility assessment — without adding to the documentation burden of an already-stretched workforce.

This means:

• •Automated SDOH-informed screening that flags transplant eligibility based on criteria that dialysis social workers already have access to, without requiring manual re-entry of data
• •Referral workflow support that surfaces the next step for a patient who meets basic criteria — so the social worker doesn't have to hold the entire eligibility criteria set in working memory across 100 patients
• •Trackable referral pipelines that let dialysis centers and nephrology teams see who is in process, who has stalled, and why — so cases don't disappear into the system

CMS will eventually develop a payment model that reaches further upstream. Until then, the dialysis centers that close this gap will be the ones with infrastructure — clinical or technological — to make systematic referral possible.

What You Can Do Right Now

If you are a dialysis patient or family member: You have the right to ask your dialysis social worker directly: "Am I eligible to be evaluated for a kidney transplant?" If you have not had that conversation, have it this week. Social workers cannot refer everyone proactively with their current caseloads — but they can respond when you ask. The question opens the door.

If you are a nephrology social worker: The referral gap is not your fault. It is a systems design failure. But you are also the person closest to the solution. Even documenting one conversation about transplant eligibility per week, per patient who meets basic criteria, creates a trackable record. That record becomes leverage — for your own caseload management, for advocacy with your administration, and for demonstrating that the referral process needs more infrastructure.

If you are a dialysis medical director or administrator: IOTA puts pressure on transplant centers. That pressure will eventually flow upstream to you, in the form of requests for referrals. The question is whether you have a systematic process to generate them — or whether you're going to improvise when the transplant center calls asking why their numbers aren't moving.

If you are a policymaker or grant reviewer: The next IOTA-adjacent policy opportunity is upstream. Funding dialysis-level referral infrastructure — social work capacity, SDOH-integrated screening tools, trackable referral workflows — would directly close the gap that IOTA cannot reach from its current position.

The Bottom Line

IOTA is a step forward for transplant hospitals. It is largely irrelevant to the 60 to 80 percent of ESRD patients who will never make it past their dialysis social worker's caseload to be referred in the first place. The referral gap is where lives are lost — and it lives at a level CMS has not yet touched.

The policy conversation is moving in the right direction. But the patients dying on dialysis today are not waiting for the policy conversation to catch up. They are in dialysis chairs three times a week, with social workers who are doing their best inside a system that was not designed for what they're being asked to do.

Closing the transplant access gap means closing the referral gap. And closing the referral gap means building infrastructure at the dialysis level — not just incentivizing better performance at the transplant level.

That's the work. IOTA started it. Now somebody has to finish it.

Matthew Sexton, LCSW, is the founder of Mental Wealth Solutions PLLC and the developer of TransplantCheck, an ESRD screening and referral platform designed to close the upstream referral gap at the dialysis center level. If you work in dialysis, nephrology social work, or transplant medicine and want to explore what a systematic referral workflow could look like for your program, the pilot waitlist is open at transplantcheck.org/pilot.