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In December 2025, the Centers for Medicare and Medicaid Services (CMS) announced the Long-term Enhanced ACO Design (LEAD) Model. Set to run from 2027 to 2036, the longest time horizon that CMS has tested to date, LEAD introduces several features to encourage coherent trajectories of care, including population-based payments, more predictable benchmarking, and episode-based risk arrangements to facilitate contracting between specialists and accountable care organizations (ACOs). To complement this design and realize the model’s potential, CMS needs an updated quality measurement framework that similarly captures the full care trajectory.
Existing Measurement Gap
To understand the limitations of current approaches to quality measurement, consider the story of a woman I met a few years ago, whom I’ll call Clara. In her early twenties, Clara developed finger numbness and handwriting difficulty, which her primary care physician attributed to carpal tunnel syndrome. She subsequently developed acute vision loss and went to the emergency department, where she was diagnosed with migraines. Treatment had little effect, so she saw an ophthalmologist, who identified blind spots and ordered a brain MRI, cautioning that he would be unable to follow the results since the study fell outside his usual purview. When Clara eventually reached a covering physician in primary care, she was sent back to the emergency department: The scan showed demyelinating disease consistent with multiple sclerosis. Even after receiving a correct diagnosis, months passed before she secured a referral to a specialist who could manage her condition—months during which she received contradictory prognostic information, began a treatment whose risks she did not understand, and ultimately abandoned her career plans to focus on coordinating her own care.