The Lead Model and the Remaining Structural Limits to Fee-for-Service Value-Based Care

Kevin Malone, Mark Lutes and Christine Burke Worthen, Members of the Firm in the Health Care & Life Sciences practice, co-authored an article in Health Affairs, titled “The Lead Model and the Remaining Structural Limits to Fee-for-Service Value-Based Care.”

Following is an excerpt:

The Center for Medicare and Medicaid Innovation’s (CMMI’s) Long-term Enhanced ACO Design (LEAD) Model, set to begin in 2027, adopts several features long associated with Medicare Advantage (MA): prospective capitated payments, beneficiary engagement incentives, premium buydowns, and downstream specialist risk arrangements. The details released with the LEAD Request for Applications (RFAs) in April 2026 substantially expands accountable care organizations’ (ACOs) financial responsibility through longer measurement periods, elimination of re-benchmarking, and greater downside risk exposure; what one analysis characterized as bringing certain MA-like features into original Medicare.

Having advised both MA plans and ACOs since the inception of the Medicare Shared Savings Program (MSSP), we observe that the two programs differ not only in whether financial risk is assumed but in how provider behavior is influenced, how integrated care infrastructure is sustained, and how rates are set and risk is adjusted. LEAD represents a serious engineering effort, and the 10-year performance period without re-basing is unprecedented for an ACO initiative. In this Forefront article, we identify where LEAD’s design closes structural gaps between fee-for-service ACOs and MA plans, and where it does not.