Kevin Malone, Mark Lutes, and Christine Burke Worthen Co-Author Article in Health Affairs on Structural Gaps Between the New LEAD Model and Medicare Advantage

Medicare's new LEAD Model has drawn attention for bringing Advantage-style payment mechanics into traditional fee-for-service accountable care.

Whether those mechanics close the structural gap between the two programs is a harder question.

Kevin Malone, Mark Lutes, and Christine Burke Worthen, Members of the Firm in the Health Care & Life Sciences practice of Epstein Becker Green, co-authored "The LEAD Model and the Remaining Structural Limits to Fee-for-Service Value-Based Care" in Health Affairs.

Drawing on their experience advising both Medicare Advantage plans and ACOs since the inception of the MSSP, the authors examine where LEAD closes structural gaps with MA, and where it does not. LEAD adopts several MA-style features for the first time in fee-for-service ACOs: prospective capitated payments, beneficiary engagement incentives, and downstream specialist risk arrangements. Its 10-year performance period with no re-basing is unprecedented for any ACO initiative. The authors identify where that design advance meaningfully narrows the gap and where structural differences in how provider behavior is influenced, how integrated care infrastructure is sustained, and how rates are set and risk is adjusted remain unresolved.

The mechanisms that give MA plans operational control over integrated care (prospective rates, enrollment-based authority, utilization management, network contracting, real-time data, integrated Part C and D payment) have no full counterpart in the MSSP or LEAD. In some areas LEAD narrows the gaps (stable 10-year benchmarks, Part D buydown, CARA). In others, the gaps remain substantial (retrospective settlement with a 9–15-month lag, request-based claims data, absence of prospective provider-network authority, discretionary fraud-related reopening). Financial responsibility and operational authority have been calibrated differently in MA and in fee-for-service, and LEAD recalibrates the financial side without fully aligning the operational side.

Get in Touch

To learn more about this topic, contact Kevin Malone at kmalone@ebglaw.com, Mark Lutes at mlutes@ebglaw.com, or Christine Burke Worthen at cworthen@ebglaw.com.