Medicare’s ACO reset puts advanced kidney care at a crossroads
Medicare is preparing for a major accountable care transition, and nephrology is being asked a hard question before the new model even starts: where does kidney care fit once the current kidney-specific arrangement disappears? The Long-term Enhanced Accountable Care Organization Design, or LEAD, is scheduled to begin in 2027 as a 10-year test meant to make accountable care more stable, inclusive and better aligned with patients who have complex needs. At nearly the same moment, the Comprehensive Kidney Care Contracting model, Medicare’s principal accountable care structure for people with advanced kidney disease, is scheduled to sunset in 2026.
The timing creates a policy gap with direct bedside consequences. If CMS allows CKCC to end without a successor, kidney care could lose a specialized framework built around nephrology-led coordination, dialysis preparation, transplant access and longitudinal accountability. LEAD is designed to widen the accountable care tent, but the new model is still organized around primary care. Advanced kidney disease does not follow that script.
CKCC built a nephrology-centered model around a high-risk population
Patients with advanced chronic kidney disease and end-stage renal disease sit among Medicare’s most medically complex beneficiaries. They often live with multiple chronic conditions, require repeated specialist input and move across outpatient, inpatient and dialysis settings with little margin for fragmentation. The burden is visible in utilization: this population experiences 1.5 hospitalizations per person-year, a rate that reflects how quickly kidney decline can destabilize the rest of the body.
The financial stakes are equally stark. The cost of care for the 3.8 million Medicare fee-for-service beneficiaries living with CKD reached $141.1 billion in 2023, accounting for 36% of total Medicare fee-for-service spending that year. Per-person spending for beneficiaries with CKD exceeded $31,000 annually, about 2.5 times the cost for Medicare fee-for-service beneficiaries without CKD, diabetes or heart failure. For beneficiaries receiving in-center hemodialysis, annual spending averaged more than $103,000 per person in 2023.
CKCC was built to answer a familiar problem in kidney medicine: the system tends to react after the crisis begins. Under fee-for-service payment, there is little reliable support for interdisciplinary teams, patient education, medication management, transition planning, analytics or the sustained outreach needed to keep advanced CKD from spiraling into avoidable hospital use and unplanned dialysis starts. Nearly half of patients with stage 4-5 CKD do not see a nephrologist, and up to 70% begin dialysis unexpectedly in an acute setting. In kidney disease, an emergency start is often a marker of missed preparation, incomplete counseling and a broken continuum of care.
Better starts, more home dialysis, and stronger transplant preparation
CKCC was designed around the clinical reality that the nephrologist often becomes the central clinician as kidney disease advances. Kidney Contracting Entities bring nephrologists together with transplant providers and, in many cases, kidney care organizations and other partners. They take on responsibility for both quality and total cost, while tailoring interventions to the full disease trajectory. The model supports slowing progression where possible, preparing patients for dialysis before crisis, increasing home dialysis use, improving access to transplantation and helping patients understand their options before treatment decisions are forced by acute deterioration.
The second independent evaluation of the model, released earlier this year, points to measurable gains in exactly those areas. Optimal starts to treatment for ESRD 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 matter because they describe care that begins earlier and proceeds with more deliberation. A better ESRD start is not just a billing outcome; it usually means vascular access planning, modality counseling and fewer rushed transitions into dialysis. More home dialysis training and higher home dialysis use suggest the model is helping shift care toward treatments that may fit patient preferences and can reduce the sense of abrupt dependence on center-based dialysis. Preemptive transplant waitlisting is equally important because transplant readiness depends on early referral, workup and sustained navigation, all of which can be derailed when kidney disease is managed too late.
One sentence captures the stakes: unplanned dialysis starts remain one of the clearest signs that the care pathway has already failed.
LEAD may welcome specialists, but kidney disease needs more than episode pricing
LEAD opens the door for specialty participation in accountable care, and one mechanism may be especially relevant: CMS-Administered Risk Arrangements, a voluntary LEAD initiative that lets accountable care organizations establish episode-based risk arrangements with specialty providers. Through CARA, ACOs and specialists can negotiate target prices for defined episodes of care and share accountability for cost and performance. In principle, that could strengthen specialist engagement and create more room for kidney expertise inside broader accountable care structures.
But episode-based risk is not the same as a kidney-specific longitudinal model. Advanced kidney disease unfolds across years, not a single episode. Patients may move through CKD progression, dialysis initiation, transplant evaluation and supportive care, with each phase requiring different expertise and different coordination demands. An arrangement built around discrete episodes may complement nephrology, but it does not fully replace a structure designed for ongoing, nephrologist-led accountability.
The distinction becomes clearer when the disease course is viewed clinically. Kidney failure affects volume status, anemia, mineral metabolism, medication dosing, cardiovascular risk and access planning all at once. The clinician who can integrate those decisions over time is often the nephrologist, not a general accountable care entity whose center of gravity remains primary care. That makes kidney medicine different from conditions where episode framing captures most of the care burden.
CMS now faces a structural decision, not just a model transition
CMS has not announced whether accountable kidney care will continue through an extension, a successor model or a defined specialty track within LEAD. That uncertainty matters because CKCC has already built clinical infrastructure, care processes and provider investment over time. Ending the model without a clear continuation risks dispersing the coordination gains that have begun to take shape.
A successor does not have to copy CKCC line for line, but it does need to preserve what CKCC made possible: nephrology-led accountability, longitudinal management and incentives that reward earlier intervention rather than late rescue. The next structure should be able to support the practices that reduce crash dialysis starts, expand home dialysis training and improve transplant readiness. Without those elements, kidney care would be folded into a model that was not built for the tempo and complexity of advanced renal disease.
CMS now has a chance to decide whether kidney care remains a distinct specialty pathway inside accountable care or becomes another condition expected to fit a primary care framework that only partially matches its needs. The unanswered policy question is how Medicare will preserve dedicated kidney accountability once CKCC sunsets and LEAD begins.