LEAD provides ACOs and providers with a wealth of tools to transform how services are delivered to beneficiaries.

• Because the model is being tested through CMMI, it includes several voluntary waivers of Medicare requirements that are not available in MSSP, which is a permanent program governed by statute and annual regulations. For example, LEAD participants will have access to several optional benefit enhancements and beneficiary engagement incentives that allow for novel care delivery patterns outside of Traditional Medicare (e.g., general vs. direct supervision of nurses during home visits, concurrent hospice care and expanded nutrition supports).
• LEAD will also test a new, voluntary CMS-Administered Risk Arrangements (CARA) initiative that allows ACOs participating in the Global (100%) risk option to enter into episode-based risk arrangements with specialty providers with analytical and payment operational support from CMS. Health systems interested in developing downstream value-based care contracts with specialty providers in their network could benefit from CMS’s administrative support in executing those contracts.
• LEAD promises to support decision-making regarding technology investments by creating a facilitated channel through which vendors can share information about their technology applications. This may benefit health systems that have not yet adopted technologies to support population health initiatives.

While MSSP also serves as a chasse for population health innovation by nature of the accountability structure, data sharing and quality goals, there are fewer add-on enhancements available to its participants due to the nature of the program.

Bottom line: LEAD may be a stronger choice for more nimble organizations who either have experience in CMMI models or have a forward-looking approach to population health redesign. However, both programs require commitment to a population health approach to realize shared savings.

MSSP may guarantee greater stability and consistency for participants, though some organizations may receive more support in LEAD.

LEAD:

• LEAD is testing new benchmarking and financial arrangements that could introduce uncertainty for participants.
• While some design changes can increase volatility, CMMI’s administration of LEAD means CMS can more swiftly address program concerns without rulemaking.
• LEAD does have specific design considerations to support ACOs that are small, rural or serving significant proportions of high-needs beneficiaries. For example, LEAD allows ACOs with at least 40% of attributed beneficiaries considered high-needs to meet a lower attribution minimum (ACOs must have at least 800 beneficiaries for their first LEAD performance year versus at least 5,000 beneficiaries for MSSP).

MSSP:  

• Material changes to MSSP’s program design must be promulgated through rulemaking or, if beyond the scope of the current program, through statute. These features insulate participants from unexpected program updates that can sometimes accompany CMMI models, which are governed at the discretion of the current Administration and may experience more volatility by nature of their demonstration status. For example, ACO REACH experienced several key program updates as a result of the 2024 administration change, which introduced new leadership and CMS priorities (as well as the ).
• MSSP also has a well-established glide path for new ACOs to gradually assume financial risk. While LEAD also has lower-risk options, health systems and other potential participants may experience challenges modeling what their benchmarks may be under LEAD given new methodologies.
• MSSP also benefits from operational maturity. With more than a decade of accumulated experience, participants can leverage established lessons and workflows. LEAD participants may need more time to adjust operations to the new CMMI model and create new playbooks for success.

Bottom line: MSSP may be a stronger choice for health systems less tolerant to risk or larger health systems whose organizational culture would benefit from greater program stability to improve buy-in across the organization.

Financial success in either program will be highly dependent on the ACO’s patient population and provider network.

LEAD:

• LEAD provides ACOs with the chance to achieve up to 100% first-dollar shared savings under the Global risk option.
• LEAD also offers several levers to improve cashflow for participating ACOs: participating providers will receive monthly capitated payments for primary care services, and ACOs have the option to provide sub-capitated payments to preferred specialty care providers.
• High needs beneficiaries become their own population type. These beneficiaries receive a distinct benchmark, trend factor and concurrent risk adjustment (like they currently do in the High Needs ACO track in REACH), but now, any ACO can benefit from these high needs-specific benefits for their high-needs patients.
• As noted above, LEAD’s CARA options can also ease health systems’ challenges with executing value-based care arrangements with specialty providers. These arrangements could prove to be another avenue for ACOs to achieve positive financial returns through stronger incentives to improve beneficiary care coordination with specialty providers who may previous have resisted or struggled to engage with value-based initiatives.
• Certain LEAD ACOs can also receive upfront payments (1.5% of benchmark) for capital and infrastructure investments.

MSSP provides a more straightforward program design.

• MSSP has several design elements that reduce financial risk for ACOs in comparison to LEAD: rather than a benchmark discount, MSSP includes a minimum savings/losses rate; risk-sharing is capped at 75%; and CMS has recently fixed a well-known methodology issue that alleviates the “ratchet effect” by giving experienced ACOs “credit” for past savings, folding a share of previously generated savings back into their benchmark so prior success doesn't become a permanently harder target.
• ACOs and health systems are able to model financial success more easily, drawing not only on CMS's public data and methodology documentation but on years of accumulated industry experience with MSSP.
• While design and methodology concerns exist, these issues and their impacts are well known.

Bottom line: The bells and whistles of LEAD’s benchmarking, risk arrangements and payment options may be attractive to ACOs and health systems that can effectively serve its patient population (especially if the population is high needs) and has strong partnerships with specialty providers. However, these features could complicate implementation and introduce challenges that could negatively impact financial success. Some health systems may be inclined to wait for additional details on LEAD (including the experiences of those that begin participation in 2027) to inform whether they apply for a subsequent LEAD application cycle. This will likely be an ongoing decision-making process for many health system leaders.