Why it’s key to build bariatric–transplant clinics in the IOTA era
Under IOTA, savings are paired with direct payment bonuses for faster time-to-transplant, making surgical weight-loss programs fiscally compelling.
On July 1, the Centers for Medicare & Medicaid Services transitioned kidney-transplant reimbursement from a process-based system to a performance-based system.
Under the new Increasing Organ Transplant Access (IOTA) Model, hospitals will be rewarded or penalized according to three key metrics – the number of kidneys they transplant, the speed at which they do so and the success rate of those grafts.
For programs that still tell candidates with a BMI of more than 40 to “come back lighter,” the model is a double-edged sword. My MUSC review showed that candidates who underwent sleeve-gastrectomy reached transplant 7.5 months sooner than peers who relied on dieting alone. That 230-day head start trimmed roughly $56,000 in dialysis spending and still left a net savings of about $42,000 after the cost of surgery.
Under IOTA, those savings are now paired with direct payment bonuses for faster time-to-transplant, making surgical weight-loss programs not just clinically sensible but fiscally compelling.
How a clinic works in practice
The concept is simple; bring together transplant surgeons, bariatric surgeons, nephrologists, dietitians, social workers, pharmacists and an insurance navigator in one clinic — whether real or virtual — so that a high-BMI patient can walk through a single front door.
Weekly multidisciplinary huddles replace the old serial-referral shuffle. The navigator packages every clearance letter in a single submission rather than three. And telehealth slots enable rural patients to complete nutrition or postoperative visits without a day-long drive.
Inside that framework, weight management proceeds along two coordinated tracks. Metabolic surgery remains the most reliable option when BMI is deep in the 40s. However, GLP-1 agonists such as semaglutide or tirzepatide give patients who cannot or should not have an operation a medically supervised path to similar weight loss over 12 months.
Exercise physiologists conduct “pre-hab” sessions to enhance cardiopulmonary fitness, and pharmacists monitor the absorption of immunosuppressants after surgery to ensure stable drug levels.
Just as important is what happens behind the scenes. Every month, the team stratifies results by race, sex and ZIP code. In the MUSC data, Black women who gained surgical access reduced their wait time from roughly 944 to 520 days, a 14-month equity dividend that listing rules alone never delivered. Tracking those numbers in real time signals whether the clinic is closing or widening disparities.
The financial math in plain English
Dialysis costs Medicare about $246 a day. A sleeve-gastrectomy averages $14,000. When surgery removes 230 days from the dialysis calendar, as it did in our cohort, the government still collects more than $40,000.
Now layer on IOTA. A hospital that consistently shortens wait times will score higher on CMS’s quality ledger and earn positive payment adjustments. What was once a break-even proposition is suddenly a revenue-positive one.
In light of these results, stakeholders should pursue several action points.
Transplant centers should formalize a joint clinic with bariatric surgery before the end of this calendar year. The most common reason candidates never reach the operating room is an insurance denial; embedding a full-time benefits specialist who handles both transplant and bariatric documentation can cut rejections in half.
Bariatric programs can reserve predictable operating-room blocks for dialysis patients and adopt enhanced-recovery protocols to keep length-of-stay low, which is essential now that IOTA also measures postoperative outcomes.
Community nephrology and dialysis units must shift the referral trigger upstream. Sending patients when their eGFR dips below 25, as opposed to the customary 20, buys extra months for weight reduction before the BMI rule comes into play.
Payers should classify pre-transplant metabolic surgery and GLP-1 therapy as medically necessary. The cost-offset argument is stronger than ever. Under IOTA, denying coverage may ultimately result in higher costs for payers.
Policymakers can modernize listing criteria by allowing “conditional listing” after a high-BMI candidate has enrolled in an integrated clinic, rather than waiting until the weight is entirely off. That single adjustment could shave months from the national wait list without compromising surgical safety.
What success will feel like
Within a year of launch, a well-run bariatric–transplant clinic should see at least two out of five patients with a BMI of more than 40 will achieve a surgical or medication milestone within six months and experience at least a one-third reduction in average time-to-transplant compared to 2019.
Most importantly, listing and transplant rates for Black women should be statistically indistinguishable from those for White men, which is something siloed care has never accomplished.
Offering a surgical weight-loss pathway to dialysis patients once felt like a benevolent extra. Under IOTA, it has become a core operational requirement. Every additional month a patient spends on dialysis now dents the hospital’s quality score and its bottom line.
No transplant program can meet the new benchmarks while leaving its heaviest candidates waiting outside the front door. The template is clear, the economics are favorable, and the equity upside is enormous. All that remains is execution, and on that front, the clock is already running.
Zachary W. Sutton, DHA, MS, MSPAS, PA-C, DFAAPA, FACHDM, is the transplant program coordinator and transplant advocate at MUSC.