March 30, 2026

STATEMENT FOR THE RECORD

“Improving Kidney Health Through Better Prevention and Innovative Treatment”
U.S. House Ways and Means Health Subcommittee

Accountable for Health is a nonpartisan national advocacy and policy analysis organization accelerating the adoption of effective accountable care. We aim to support policymakers to advance the movement in the health care system toward accountable care that achieves better outcomes, improved care experiences, increased access and lower costs.

Beneficiaries with chronic kidney disease (CKD) and end-stage renal disease (ESRD) represent one of the highest-need and highest-cost populations served by Medicare. While these individuals make up a relatively small share of total beneficiaries, they account for a disproportionate share of Medicare spending. Kidney disease is also deeply interconnected with other chronic conditions, particularly diabetes and hypertension, which are among the leading drivers of disease progression. Yet CKD often advances silently, with few or no symptoms in early stages, leaving many patients undiagnosed until they require intensive, life-sustaining interventions such as dialysis or transplant. This underscores the urgent need for policies that prioritize early detection, prevention, and longitudinal care management.

As kidney disease progresses to advanced stages, care becomes increasingly complex and resource intensive. Patients with Stage 4–5 CKD or ESRD require highly coordinated, specialty-driven care that addresses dialysis, transplant preparation, comorbid conditions, and ongoing care management. Nephrologists serve as the central coordinators of this care, yet traditional Medicare fee-for-service (FFS) payment does not adequately support the infrastructure required to deliver comprehensive, team-based, and proactive care. General primary care–based models are similarly not structured to meet the intensity and specialization required for this population.
A substantial body of evidence demonstrates that consistent, multidisciplinary nephrology care improves outcomes and reduces avoidable utilization. Studies have shown that coordinated care models can reduce mortality, decrease hospitalization rates, slow disease progression, and improve dialysis preparation. These findings highlight the importance of aligning payment with care delivery models that enable earlier intervention and sustained patient engagement.1

Kidney-specific value-based care models build on this evidence by enabling tailored interventions that are uniquely effective for this population. These models support delaying disease progression, improving dialysis preparedness, increasing access to transplantation, expanding home dialysis adoption, and reducing avoidable hospitalizations. The Comprehensive Kidney Care Contracting (CKCC) model represents a significant step forward in this regard.

Specialty Models Work for Kidney Care

Kidney care is particularly well-suited for value-based care (VBC) models. This is driven by several factors: the high and concentrated cost of the patient population, the ability to meaningfully influence those costs through coordinated and preventive care, and the frequency of patient interaction with the health care system, particularly with nephrologists. Unlike many other chronic conditions, kidney disease has clearly defined stages and objective clinical metrics, enabling more precise attribution, monitoring, and accountability within a VBC framework.

Traditional FFS payment models reward volume rather than outcomes, creating misaligned incentives that contribute to fragmented care and higher costs. In contrast, specialty-focused VBC models incentivize care coordination and proactive management, which in turn drive better clinical outcomes and more efficient use of resources. Kidney care patients, who have frequent and predictable touchpoints with the health care system, are especially well-positioned to benefit from these models.

The CKCC model, launched by the CMS Innovation Center in 2022 as part of the Advancing American Kidney Health initiative, builds on earlier models by expanding upstream to include late-stage CKD and focusing on reducing fragmentation, enhancing coordination, and improving outcomes. Early results from CKCC demonstrate meaningful improvements in care delivery, including increased rates of optimal dialysis starts, greater adoption of home dialysis, and increased pre-emptive transplant referrals. These improvements reflect stronger care coordination and earlier patient engagement, which are critical to improving both quality and long-term cost outcomes.2 Early evaluation findings from Performance Year 2023 further reinforce these trends, showing more patients initiating treatment through planned pathways rather than emergency dialysis, along with continued improvements in care coordination, disease monitoring, and preparation for dialysis. The model has also supported increased use of home dialysis and growth in living donor transplants, reflecting more patient-centered care delivery.3

Programmatic Stability is Needed

While the CKCC model has begun to demonstrate promising improvements, continued transformation in kidney care requires programmatic stability and a sustained commitment to the model. Participating organizations have made significant investments in care teams, clinical workflows, health information technology, data analytics, and patient engagement infrastructure. These investments are essential to delivering high-quality, coordinated care but require a predictable and stable policy environment to be maintained and expanded.

The CMS Innovation Center has statutory flexibility to modify models during implementation, and recent changes to CKCC for performance year 2026 reflect efforts to refine the model. However, frequent or significant redesigns risk undermining the model’s progress, disrupting care delivery, and discouraging provider participation.

Transforming care delivery, particularly in specialty care settings, requires time for practices to adapt workflows, integrate new capabilities, and realize the full impact of investments. Abrupt changes or discontinuation of the model would not only jeopardize current gains but could also signal instability across CMMI models more broadly, discouraging future participation by specialists.

Sustained engagement from nephrologists is essential for the success of kidney-focused value-based models. Ensuring program continuity and minimizing unnecessary disruption will allow the model to mature, enabling both improved patient outcomes and long-term savings to the Medicare program.

Current Evaluation Approaches Undermine Accurate Assessment of Model Performance

Current evaluation approaches are not well-suited to accurately determine savings in kidney care models and are generally problematic in assessing true performance.

Evaluations typically rely on retrospective claims data that lags by up to two years, creating a mismatch between when care transformation occurs and when its impact is measured. For a chronic condition like kidney disease, where interventions to slow progression, improve dialysis preparation, and increase transplant rates may take years to translate into measurable cost savings, this delay risks understating model impact.

In addition, existing frameworks focus heavily on short-term spending and do not capture early signs of improved care, such as increased home dialysis use, higher rates of optimal dialysis starts, improved transplant referrals, and better care coordination, all of which come before longer-term savings. Evaluation methods also do not fully account for the upfront investments required to implement specialty value-based care models, including care teams, infrastructure, and data capabilities, and are further complicated by ongoing model changes that make it difficult to isolate true performance. Together, these limitations highlight the need for evaluation approaches that use longer timeframes and better reflect how kidney disease progresses over time.

******
Thank you for reviewing this statement. We respectfully urge Congress to consider the above as it evaluates legislative and regulatory actions to improve kidney health through stronger prevention, earlier intervention, and the advancement of innovative, accountable care models. Ensuring the long-term stability and effectiveness of kidney-focused value-based care models will be critical to improving outcomes for beneficiaries while supporting the sustainability of the Medicare program.

Please do not hesitate to reach out if Accountable for Health can be a resource to you. I can be reached at mmcdermott@accountableforhealth.org.

Sincerely,

Mara McDermott
CEO
Accountable for Health