Navigating the Next Chapter of CMS Value-Based Care: LEAD, MSSP and Beyond

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Daniel Marino:

Welcome to Value-Based Care Insights. I am your host, Daniel Marino. As we've talked about time and time again on the program, value-based care continues to pick up momentum. And not only is it occurring, as we mentioned, in the commercial space, but certainly CMS continues to, evolve, continues to introduce new programs, and we're at a bit of a pivotal moment, if you will, on some of the value-based programs that CMS continues to introduce to providers. And if you think about it over the past decade, it's been an interesting journey, where CMS has tested a number of programs, right? I mean, we started out with the straight MSSP, the Pioneer program, went to NextGen, direct contracting, and then most recently, we've had the ACO REACH, which is sunsetting at the end of this year, and now we've got some new programs, some new chapter of the CMS programs, and it's LEAD that is replacing REACH, as well as then the team model and the continued evolution of MSSP. And… I find in many of my conversations that many of the providers, although they've begun to evaluate and identify what direction they want to go, are still a little bit leery about what that program is really… means to their organization. How can they continue to be successful in it, or what do they need to do in order to create their value-based care operating model to ensure the right level of performance and financial success.

I'm very excited today to have on our program Emily Brower. Emily is President and CEO of the National Association of ACOs. Emily brings decades of experience leading clinical integration, population health, value-based care, strategies for… not only for NAACOS, but she has worked with other provider organizations over the years. She's been the president of NAACOS since 2025, and is a longtime member and board member of NAACOS. Emily, welcome to the program.

 

Emily Brower:

Thanks, Dan. So pleased to be with you today.

 

Daniel Marino:

So, Emily, maybe for our listeners, I think most of our listeners understand or know of NAACOS, but I think it would be helpful if you could just give a quick little overview. What is NAACOS doing? What is kind of the priorities that you have for the organization?

 

Emily Brower:

Yeah, thanks for that. So, NAACOS, National Association of ACOs, is the preeminent organization advancing provider-led healthcare transformation that is resulting in better care, better health, and smarter spending for the people they serve in their communities. We were founded in 2012 by some of the earliest ACOs. To meet the educational and advocacy needs that they saw, for them and for a growing industry. So we are truly a member organization governed by our members, and we, with our members, have shaped the healthcare landscape to advance those models. Accountable care, scaling best practices across the United States. Our members represent 500, nearly 500, accountable care organizations, so almost all of those provider organizations that are participating in accountable care models. And together, they, improve outcomes for more than 10 million beneficiaries across Medicare, Medicaid, and commercial insurance.

 

Daniel Marino:

I've had the opportunity over the years to, to participate in a few of the conferences, and many of our clients, work with NAACOS. You all do some phenomenal work, and I think the voice of the ACOs in particular has been just an amazing value add for a lot of our providers. So let's dive into this, because I have a number of questions I think you could help work through. Let's talk about LEAD. Many of our providers are thinking through whether they transition, from REACH to LEAD, or do they, you know, they stay in the MSSP. As we think about LEAD as that next generation of the accountable care model. What are… what are some of the big drivers there? What are the things that, as organizations have moved into LEAD, or considering moving into LEAD, what are they thinking about? What are those drivers of success?

 

Emily Brower:

Yeah, thanks. So it has been, and this year, 2026, we've seen, both the introduction of LEAD and, some proposed changes in the Medicare Shared Savings Program, so the permanent program, if you will, alongside those changes in the latest, Innovation Center, program that really respond to…NAACOS and our members' ongoing advocacy to grow and sustain accountable care. So we are seeing very specific design elements there, that will make 2027 be an important year for, for growth and sustainability. And, it really has prompted, our members, all ACOs, I would guess, to take a fresh look. Sort of who they are, what they're good at, what their thesis is around how they're going to transform healthcare delivery for their communities, and look at 2027 and how they participate in these models, really bringing… bringing both that experience and those strengths matched with some of these, design changes that, that will enable them to, to grow and sustain that work.

 

Daniel Marino:

So, REACH was a 3-year program that ends at the end of this year. LEAD is a 10-year program, volunteer 10-year program. So it's quite the commitment, and I know some of the, you know, some of the key components of LEAD is, as well as that 10-year performance period, there's, you know, different risk tracks, a global and a professional risk track. There's, you know, specialty integration is a big component of that. As organizations are thinking about advancing from REACH to LEAD, and as they start to think about all of the elements. What do you think the intention is of CMS to work with the providers in this next generation of this type of a model? Any thoughts in terms of what, you know, what CMS is really hoping to accomplish during this period?

 

Emily Brower:

Yeah, so you mentioned a couple of things that are design elements that reflect, right, their thinking and how to advance, and sustain these models. You mentioned the 10-year time frame. So, one of the things that, that we know about Innovation Center models is, is they are, in fact, innovating, pioneering, testing approaches, so being able to do that within a longer-term model is then, sort of matches our members' interest in those longer-term investments, even if there are innovations and changes along the way. So I think that 10-year, trajectory is very responsive to the kinds of investments ACOs make, which go way beyond 1, 2, or 3 years. You think about, the investments to… to not, just address and manage chronic disease, but actually reduce the incidence and prevalence of chronic disease, right? Those are long-term you make with your clinical teams, with your network, with care management, with new programs and investments. So again, that longer-term trajectory is nicely matched with the way our members think about the work that they're doing to improve the health of the communities they serve.

 

Daniel Marino:

One of the challenges that I continued to hear around, the REACH program was investments in care management and analytics and managing population health, only to see some of the benchmarks reset before they've really realized the benefit. And to your point, right, the investing in chronic diseases, you want to invest in preventative care services now, with the idea that over the long term, you're going to start to see the total cost of care reduced, right? So as the structure of LEAD is thinking about that larger performance here, that larger 10-year performance here, do you feel like this would be a better opportunity for providers to see a return on their investment as they start to look to invest in that infrastructure with the outcomes occurring, say, in 4, 5, 8, 10 years down the road.

 

Emily Brower:

Well, so there are a lot of things that go into that, right? You really have to know who you are. What your network can deliver, and… and have a very strong, hypothesis around how you're gonna, change the health of those communities. With LEAD there are… there are, there are many features that have to do with downstream payment, so if you are coming at this work thinking that how you're going to get engagement and change among providers, among beneficiaries, and communities is by having payment flexibilities. LEAD is for you. There's lots of payment flexibilities built into those models. Building off of those offered in earlier models, next generation, REACH, Right? And now we see in LEAD. So, I think it has a lot to do with… for the ACO, how they see, the different levers they can pull to improve health, better care, more smarter spending. If that involves changing the way people are paid. Than, than LEAD is for you.

 

Daniel Marino:

Yeah, I love that, and I think I've often said time and time again, form follows function, and I think you have to have the right incentives, you have to have the right structure in place, so you create the right behaviors that are supporting your overall goals and the infrastructure, and that sort of thing. And I agree with you, I think it's exciting that that type of payment structure, that flexibility built into LEAD, you know, that I think is going to be a nice benefit. Let's switch over real quick to the MSSP. Again, the MSSP is continuing to evolve, but unlike LEAD, it is still based on the traditional Medicare fee-for-service reimbursement. There's a shared savings component. It's a little easier to get into it. Do you feel like it's still keeping up with where organizations are as they progress more into the population health realm and being able to identify some of those opportunities that they need to solve for as they're taking care of the patients in their community?

 

Emily Brower:

Yes, and I would say particularly with, some of the changes that… that we and our members have advocated for. So, in any of these programs, including in… in commercial accountable care, Medicaid value-based payment, right, in all of these. You need to have really good insight into, what is the benchmark or the budget that you are working, to, to perform within and create savings against, right? So, how that is created is a little different, in different models, and one of the things that was becoming problematic in the Medicare Shared Savings Program was how, certain design elements around that benchmark or budget, and how it gets trended, not to get too weedy, but the accountable care perspective trend, designed to sort of, to… to… to sustain, the improvements that ACOs make as they move away from fee-for-service. That, that had some flaws, and so there have been, changes. So, CMS has made changes to that to address some of those flaws. So that is very, very important, right? You are looking to make investments, understand the patterns and cost of care of your population. And then take a look and say, okay, can I be successful in managing that against this benchmark or budget? You need to know what that number is.

 

Daniel Marino:

If you're just tuning in, I'm Daniel Marino, and you are listening to Value-Based Care Insights. I am here today talking to Emily Brower, President and CEO of NAACOS, and we are diving into the new, or evolving CMS ECO programs that we're going to be seeing in 2027. So, I know, Emily, there's still a number of proposed CMS changes that we're working through, right? That we're kind of waiting to see how this is…It's going to evolve, hopefully, in the next couple of months, and certainly is going to impact the operating models that providers have to put in place, you know, some of those proposed changes, you mentioned a little bit, is the benchmarking methodology. I think, obviously, the reimbursement around the fee-for-service rates and so forth. What are some of the other proposed changes that you're keeping an eye on as part of NAACOS, and hopefully able to influence a little bit on behalf of your members?

 

Emily Brower:

Yeah, so, so where we did see some, some really significant movement was, on quality, quality reporting, which was a feature of the Shared Savings Program, that the way that those ACOs, gather data and report it to CMS to demonstrate the quality of care that they're delivering, that, that needed some significant, sort of evolution and improvements to kind of catch up to, more digital-based quality measurement and the ways that today our members, ACOs, can pull data from multiple sources, put that together, and use it to demonstrate the quality that they deliver, quality reporting. So some significant, changes to that that make that program, work much better, and also enable them to bring some of those same components into the CMMI model, or LEAD, as we were talking about earlier. So, again, you see there improvements, responsiveness, and something that is a feature of both CMS and CMM models, as it is more a sustainable, platform. So we see some of that in the, in the quality side as well. Those were, some important changes.

 

Daniel Marino:

How about the finance side of it? You know, the financial modeling, obviously, is really important for organizations as they think about what direction they want to go, and especially, you know, obviously, everybody's concerned, not, you know, they're excited about the upside shared savings, but they're always very cautionary, very cautious about the downside, right? And that always ends up getting more attention. The math around this, the financial models are really critical. How are you helping organizations through this? Have… maybe you could speak to a little bit of the resourcing or the support that NAACOS provides, because I… I do know that it can get quite intricate, and especially If a lot of these financial elements aren't necessarily, decided on as we're building the model, right? It's sort of a bit of a moving target.

 

Emily Brower:

Yeah, so at NAACOS, our members rely on us, really, to do two things really well. One is to advocate for changes to the model that make, that can support growth and sustainability and performance in the model, so that's the work we do with our members, with our, CMS, partners, members of Congress, etc, on the federal models, and then we do that in a shared… in a shared, way as well with, with private insurers, particularly in Medicare Advantage, commercial Medicaid, but rely on us every day to do an excellent job on the advocacy work, and we're so pleased with all of the changes we've seen that we talked about earlier. But the other thing they rely on us for is… is to be able to get farther through learning together what works. So, we spend a good part of our time and effort on shared learning. So, whether it's to support understanding about, sort of, all the financial puts and takes that you mentioned around where is the risk. And… and how to, perform within a risk-based contract, or the shared learning around clinical models, who's really doing a great job managing heart failure, managing diabetes, managing some of the, conditions. That, are common, in the populations, that our members are accountable for. And then the other piece is around, engaging the network, how to create a network that is rewarding for physicians and other clinicians to participate in these models that really is motivating them, that feels like the way care should be delivered, the way they want to deliver care. So that's really where, we support our members. Yes, absolutely, making sure they understand all of those puts and takes around the financial model. You've got to have that, but then within the models that you've chosen. How to really hit it out of the park around those clinical outcomes and the smarter spending, you know, that all of our members are working on every day.

 

Daniel Marino:

Yeah, that's great. Well, and I give you a lot of credit for that, because that financial modeling, I mean, it's critical, right? You have to understand what direction you want to go, what, you know, what's the end result, and, you know, then it helps to kind of path, you know, create the path of success to get there. So, another question is as organizations, you know, I know many of them have already made their decision, at least for 2027, to move into LEAD or, you know, MSSP, but… but when you're thinking about that, and If a provider has had history of being successful in downside risk, or is capable in taking downside risk, given the two models, and maybe, you know, at least on the surface, the financial modeling around those. Would you view LEAD as being more attractive economically than MSSP, or does MSSP still remain fairly competitive from a shared savings perspective to really align the network. So is it more around leveraging performance, or is it more around, you know, the foundation of building the value-based care operating model, if you will?

 

Emily Brower:

So, I think at this… at this point, where we are in the evolution of these models, there are more things around the financial risk and exposure that are similar. And so, you are really, as a… as a… as an organization, looking at what is… where are my strengths? And which model is going to… is going to really leverage my strengths? If you, see a lot of opportunity in payment flexibilities, how you're going to engage and pay specialists, how you're going to pay primary care differently, as we were talking at the top of this, you know, LEAD offers that for you. So it's… and what is the population you're serving is… is another really important, feature. So, when you look at the population that's attributed to the ACO, what are those, pockets of… of particular population focus? So, LEAD has some sort of dynamics that help support a very high needs, population that has a lot of frailty and a high trajectory or increase in, in spending because of an increase in clinical needs. So, with that kind of who you serve, then, that model might work better for you. It's also got some, you know, built into the future evolution of that model, some opportunity around people who are dually enrolled in Medicare and Medicaid, so some Medicaid integration, like, if that's for you, maybe you also have a PACE program, maybe there's a focus for you on folks who are dually enrolled, and so you want to have that capability. So I would say it's more in some of those features around who is the population you're serving, and who is your network, and how do you match your strengths and what you really know about yourself and the people you serve at this point, this many years into this work. Have that lead, the decision around, which model is right for you.

 

Daniel Marino:

Yeah, that's good advice, because I think there's a lot of factors to take into consideration, and it's really around what your evolution is, of your value-based care infrastructure, your operating model, and so forth. Well, as we mentioned, you know, I've been impressed with NAACOS over the years. You have a lot of resources internally within the organization that you offer to your members. But you also have a conference coming up. I believe you. You do, right? October 14th through the 16th, and I'm sure you and your colleagues are getting ready for this. It's only, you know, in the next couple of weeks. Can you share with our listeners a few details about that?

 

Emily Brower:

Yeah, so, we do two, national conferences a year, so this is our, our Washington, D.C. conference, October 14, 15, and 16. That's where we bring together our members, of course, for some of that, shared learning, so we do a lot of that during the year in virtual formats and regional meetings, but the national meeting is a chance for people to do that together in the same space, to really hear from each other what's working. We also bring together many, of our federal partners, so we've got a whole bunch of people from CMS, CMMI, who are going to be in attendance with us as well, so… so our members also go there to hear the latest. If you're in ACO and you want to spend that time with us. We would love to have you if you're not already registered. We've got a discount code for today's listeners, VBC Insights, so when you go to register at NACOS.com, you can use that discount code, and if you're not an ACO, but you also want to learn more, so we have business partners, partners who engage with our members to support them in this work. Just email us at conference@NAACOS.com, and we can tell you a little bit more about.

 

Daniel Marino:

So, that's wonderful, and I appreciate you sharing so much about the conference. And for our listeners, we will have that link in our liner notes, as well as the discount code as well. Emily, I want to thank you for coming on the program. This has been wonderful. I feel like we just barely scratched the surface, thank you for coming on the program.

 

Emily Brower:

Yeah, thanks so much, Dan, for having me, it's really an exciting time, so glad to be here and… and share a bit of that excitement with your listeners.

 

Daniel Marino:

Well, thank you, and thank you again, I really appreciate it. And a special thanks to our listeners for tuning in. Like always, if you are interested in hearing more about this topic, any of the topics that we talk about on Value-Based Care Insights. please visit ECGMC.com, or LuminaHP.com/insights. Until our next insight, I am Daniel Marino, bringing you 30 minutes of value to your day. Take care.

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners