Medicare’s new accountable care era cannot absorb kidney care by default
In 2027, Medicare will begin a 10-year test of the Long-term Enhanced Accountable Care Organization Design, or LEAD, while the Comprehensive Kidney Care Contracting model is scheduled to sunset the following year. The overlap is more than administrative timing. It forces a direct policy decision about whether patients with advanced kidney disease will continue to have a dedicated accountable care structure or be folded into a broader model built primarily around primary care.
Patients with advanced chronic kidney disease and end-stage renal disease are among the most medically complex people in Medicare. They often live with multiple chronic illnesses, require repeated transitions across outpatient, inpatient, dialysis, transplant, and supportive care settings, and generate heavy utilization. The care burden is not abstract. These patients experience about 1.5 hospitalizations per person-year, and nearly half of patients with Stage 4 to 5 CKD do not see a nephrologist before late-stage disease deepens.
Unexpected dialysis starts are still common.
When dialysis begins in an acute setting, the clinical consequences are immediate: fewer opportunities for vascular access planning, less time for patient education, and a higher chance that treatment begins under emergency conditions rather than with a deliberate long-term plan. That is exactly the gap CKCC was built to address.
CKCC has changed how advanced kidney disease is managed
CKCC brings nephrologists together with transplant providers and, in many cases, kidney care organizations and other partners into a risk-bearing structure that links quality and spending to actual care delivery. The model recognizes a simple fact of advanced kidney disease: as CKD progresses, the nephrologist often becomes the principal clinician coordinating decisions, not a peripheral consultant waiting on referral cycles from primary care.
The model’s care design encourages interventions that matter at the bedside and in the dialysis unit. Those include slowing disease progression when possible, preparing patients for dialysis before a crisis, increasing home dialysis use, improving transplant access, and making sure patients understand the tradeoffs among treatment paths. For a population with progressive loss of kidney function, better coordination is not just administrative efficiency. It is a way to preserve autonomy, reduce avoidable emergencies, and support decisions that align with patient goals.
Recent evaluation data show that the model is producing measurable shifts in care patterns. The second independent evaluation found that optimal starts to ESRD treatment increased by 31%. Home dialysis increased by 10%, home dialysis training increased by 22%, and preemptive transplant waitlisting increased by 37%. Patients in the model also reported receiving more information about treatment options, while patient activation scores improved over time. Those changes point to more intentional care pathways, with more patients entering dialysis or transplant planning under controlled circumstances rather than through crisis care.
Financial performance has been weaker, but that does not settle the policy question
CMS is required to test models that generate savings, improve quality, or both. On the spending side, CKCC has not yet delivered the financial performance CMS wants. The most recent evaluation estimated that the model increased net Medicare spending by $275 million in 2023. In response, CMS made major design changes for 2026, including larger benchmark discounts, a lower CKD Quarterly Capitation Payment, elimination of the kidney transplant bonus, and an extension of the model through 2027.
Those policy changes matter because they changed the economics of participation. An independent actuarial analysis by Wakely Consulting Group applied the 2026 payment policies retrospectively to earlier years and estimated that the revised structure would have reduced total model payments by about 45% in 2023 and 40% in 2024. Under that counterfactual, the model would have generated estimated net savings to CMS of $26 million in 2023 and $90 million in 2024. If current participants had been in full-risk tracks, those estimated savings would rise to $112 million and $118 million, respectively.
The lesson is straightforward: early financial results from a model that CMS has already redesigned should not be treated as the final verdict. Medicare payment reform often needs time for clinical infrastructure, data integration, patient outreach, and practice redesign to mature. The Medicare Shared Savings Program did not generate cumulative net savings for CMS until its fifth year, yet later produced sustained savings, including more than $6.6 billion in 2024 alone and $2.5 billion returned to CMS. CKCC deserves to be judged against the version that exists now, not only the one that operated before CMS tightened the rules.
LEAD may help specialists, but kidney care still needs its own accountability structure
LEAD opens the door to broader specialist participation in accountable care, including CMS-Administered Risk Arrangements, which allow accountable care organizations and specialists to negotiate target prices for defined episodes of care and share responsibility for performance. That is a useful tool. It may strengthen specialist integration inside ACOs and give nephrology a more visible role in value-based care.
But episode-based specialist arrangements are not the same thing as a kidney-specific model built around longitudinal nephrologist-led accountability. Advanced kidney disease does not unfold as isolated episodes. It moves across CKD management, dialysis preparation, dialysis maintenance, transplant planning, and supportive care. A model focused on a single episode may fit some specialist services, but it does not fully match the long arc of kidney disease progression.
CMS now has several plausible options: extend CKCC, build a successor kidney-specific model, or create a dedicated kidney track within LEAD that aligns beneficiaries through nephrologists. Any of those paths would be better than allowing kidney care to disappear into a generalist framework without preserving the structures that made CKCC clinically useful.
The next model must be easier to enter, fairer to run, and more precise in measurement
A durable kidney care model needs better participation rules. Alignment at the tax identification number level, with exceptions for hospital systems, multispecialty groups, and academic institutions where overlap rules create barriers, would make participation more workable. A 12-month look-back based on qualifying nephrology services would better reflect current care relationships. Patients with Stage 3B CKD should also have a pathway into the model, since this is the point when education, medication management, and earlier intervention can still slow progression.
The payment methodology needs similar refinement. Stage 4 and 5 CKD and ESRD should be treated as high-needs populations with concurrent risk adjustment that captures disease progression and changing treatment status during the year. Benchmarks should reflect spending patterns in these patients rather than relying on broader Medicare trends that dilute kidney-specific reality. Policies should also avoid punishing organizations for savings already generated and should preserve advance shared savings payments that support up-front investment in staffing, analytics, and outreach.
Quality measurement should be narrower and more stable. A quality withhold of 3%, consistent with LEAD, would preserve accountability without making results excessively sensitive to year-to-year statistical noise. A small set of measures, ideally three or four, would be easier for participants to influence and easier for patients to understand. Optimal Starts and the Patient Activation Measure should remain central, and a hospitalization or readmission measure could work if it is benchmarked against comparable kidney populations and adjusted for kidney-specific acuity.
Medicare can preserve kidney-specific care without abandoning accountability
The central policy question is not whether kidney care should be accountable. It already is. The question is whether Medicare will preserve a specialty-led structure that fits the biology and care patterns of advanced kidney disease, or whether it will let that structure fade just as LEAD begins.
CKCC has shown that specialty accountability can change how kidney care is delivered, with more optimal dialysis starts, more home dialysis, earlier transplant planning, and better patient education. CMS has already changed the financial levers that drove early spending results. The next step is to determine whether those revised rules can support a stable successor that keeps nephrology at the center of accountability.
For patients with advanced kidney disease, the consequences of getting this wrong are clinical, not theoretical. The next model should be built around the care they actually need, not around the convenience of a general framework.