Article
What LEAD offers
The Long-term Enhanced ACO Design model opened its application portal March 31. ACOs have until May 17 to apply, and the first performance year begins Jan. 1, 2027, after ACO REACH ends. The performance period runs through 2036.
LEAD’s central promise is stability. CMS says it will not rebase benchmarks during the model, a direct response to the ratchet effect in which ACOs that lower spending later face lower targets. Benchmarks are designed to converge over the decade. ACOs choose a Global Risk option, with full upside and downside on total cost of care, or a Professional Risk option that shares that risk with CMS. Payment choices include primary care capitation and total care capitation. Global Risk ACOs can also elect CMS-administered episode arrangements with specialists.
Most ACOs need at least 5,000 aligned Original Medicare beneficiaries, with lower minimums for new entrants and for ACOs serving high shares of high-needs or ESRD patients. Hospitals that employ clinicians can take part through a participant TIN, and critical access hospitals are eligible.
What GAO’s tally adds
A GAO report released March 27 puts the Innovation Center’s record in perspective. From 2011 through 2024 the center obligated $11.4 billion and tested 70 models. Four have been expanded nationwide, and all four produced net savings during testing. Annual obligations fell from a $1.3 billion peak in fiscal 2015 to $789 million in fiscal 2024.
The message for hospital leaders is that model rules change, many models end and very few become permanent Medicare policy. LEAD’s 10-year term is meant to address that concern, but a decade also exceeds most strategic plans and board terms.
Questions for the board before May 17
- Scale. Does the system’s employed and affiliated primary care base reach the beneficiary minimum without weakening its performance data?
- Risk appetite. Do current cost and quality results support Global Risk, or is Professional Risk the better first step?
- Overlap. Which existing programs and contracts would conflict with LEAD participation?
- Staying power. What happens to care management investments if early years underperform?
Archive entry for Apr 2, 2026, added Nov. 11, 2026.