Accountable care organization (ACO) models typically haven’t effectively engaged physicians in nonprimary care specialties or those in small, independent or rural-based practices.
But the Centers for Medicare & Medicaid Services (CMS) is looking to change that with its newest ACO model called Long-term Enhanced ACO Design (LEAD), which is set to launch at the end of 2026. The model is designed to provide a better way for primary care physicians and specialists to work more closely together to deliver high-quality, coordinated care for patients—something the AMA has recommended for several years (PDF).
LEAD aims to offer improved benchmarking to appeal to a broader mix of physicians and it has been designed for practices that have previously participated in an ACO model as well as those who have not. The 10-year performance period will provide stability for physician participants and offer sufficient time for them to gain experience and refine the ways they deliver patient care. The LEAD ACO model focuses on better care coordination for patients with complex needs, including those who are dually eligible for Medicare and Medicaid and those who are homebound or home-limited.
“Too often we’ve taken a cookie-cutter approach and not given physicians real flexibility for how to approach things. … More flexibility, less burden. That’s what matters here for setting up an accountable care organization for success,” said Abe Sutton, the director of the Center for Medicare and Medicaid Innovation (CMMI) and deputy administrator for CMS. “What we need to do is set up a structure where there’s the right incentive for folks to come in, whether you have historically costly patients, historically low-cost patients, and you can succeed. We've put a lot of thought into how to set that up, as well as what flexibilities we can give you to enable you and your patients to succeed within that structure.”
Sutton and CMMI Chief Strategy Officer Gary Bacher recently spoke about the new program with AMA CEO and Executive Vice President John Whyte, MD, MPH, for an episode of the “AMA Moving Medicine” video podcast.
Overall, the LEAD model aims to build on successes and lessons from the ACO Realizing Equity, Access and Community Health (REACH) model, Sutton said. It’s designed to set “up a long-term incentive where patients can be supported by physicians with new flexibilities, as well as a predictable structure for what the incentive is with clear data given to physicians,” he said.
More room for specialists
LEAD is a 10-year voluntary model that will run from Jan. 1, 2027, through Dec. 31, 2036. Beginning in March 2026, ACOs can apply to participate by responding to a CMS request for applications.
The AMA noted that the LEAD Model includes a stronger role for specialists, essential to patient care, especially for patients with complex or costly conditions. ACOs will be able to formally partner with specialists to care for their patients under the LEAD Model.
The LEAD Model reflects principles that the AMA has long-championed, in that value-based payment models work best when they are voluntary, led by physicians, focused on better care coordination, flexible, and designed to reduce administrative burden.
“Patients are healthiest when their primary care doctors and specialists are working as a team,” Dr. Whyte said in a statement issued Dec. 19. “By supporting team-based care, keeping participation voluntary, and offering more predictable and sustainable payments, this model has the potential to improve patient outcomes and strengthen Medicare. We appreciate CMS and the Innovation Center’s efforts and look forward to continuing to work together to make these models successful.”
How LEAD is different
LEAD aims to allow independent physician-led practices, rural practices and practices that care for specialized patients and complex patient populations to more easily participate in an ACO model in the same way other participants do.
“We’ve done some things that will be particularly helpful for them. For example, if they haven’t participated in a model before, they’ll start off with their full historical experience as the benchmark, plus an add on,” Bacher said.
He said the add-on is meant to give practices a ramp onto the model and it is then translated into a capitation payment.
“So, they’re getting better cash flow and then for those that are taking care of specialized patient populations and tend to have smaller panels, we’re giving them smaller minimum alignment level,” Bacher said.
According to the CMS website, LEAD, among other things, will provide:
- Support for high-needs patients. This includes more accurate risk adjustment and benchmarking.
- Two voluntarily risk-sharing options. Under the global risk option, practices are eligible to receive up to 100% of their savings and liable for up to 100% of total losses relative to their established performance benchmark. Under the professional risk option, practices are eligible to receive up to 50% of total savings and liable for up to 50% of total losses relative to their established performance year benchmark.
- Healthy living flexibilities. Participants can be part of the Benefit Enhancements and Beneficiary Engagement Incentives that support delivery of coordinated, proactive and preventive care.
- Medicaid integration. The goal is to create incentives, where none already exist, for Medicare and Medicaid health care providers to coordinate care and improve outcomes for dually eligible beneficiaries.
- CMS Administered Risk Arrangements (CARA). This will provide robust CMS support to ACOs to enable episode-based risk arrangements between ACOs and their specialist and provider organization to facilitate greater and stronger preferred provider relationships with these downstream health care providers. CARA also will feature an episode-based falls prevention program.
The CMS experts said it is important for the country’s health system that smaller and independent practices participate in ACOs.
“We need a system where even if you’re not part of a big hospital system, you’re able to succeed. If we can’t draw in rural practices, small practices, independent practices and give them a way to succeed in accountable care, we’re shutting them out from a path to flexibility, a path to freedom to practice and serve patients,” Sutton said.
The LEAD Model comes on the heels of the ACCESS Model, a voluntary CMS initiative to test technology-supported care for patients with chronic conditions who are covered by traditional Medicare that was launched in early December.
Visit AMA Advocacy in Action to find out what’s at stake in reforming Medicare payment and other advocacy priorities the AMA is actively working on.
