Quality

Quality Measurement and Performance

LEAD’s quality strategy balances achievable performance criteria with incentives for care delivery transformation. The model features the same claims-based and CAHPS measures used in ACO REACH, plus two new electronic clinical quality measures (eCQMs) phased in over the model period. (RFA §XI)

Quality Measures (RFA §XI.A)

4 Claims-Based Measures:

1. Risk-Standardized All-Condition Readmission (ACR): hospital readmission rate within 30 days, risk-standardized for patient characteristics
2. All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions (UAMCC): inpatient admission rate for beneficiaries with 2+ chronic conditions
3. Days at Home for Patients with Complex, Chronic Conditions (DAH): days not spent in an inpatient facility or SNF for chronically ill beneficiaries
4. Timely Follow-Up After Acute Exacerbations of Chronic Conditions (TFU): rate of follow-up visits within a specified window after an acute event

Patient Experience: CAHPS for ACOs survey (Consumer Assessment of Healthcare Providers and Systems)

2 Electronic Clinical Quality Measures (eCQMs) New in LEAD:

1. Hemoglobin A1c Poor Control: percentage of diabetic patients with A1c > 9%
2. Blood Pressure Control: percentage of hypertensive patients with BP < 140/90

eCQM Phase-In Schedule (RFA §XI.A)

Years	eCQM Requirement	What This Means
PY 2027–2028 (Years 1–2)	Optional	ACOs may report but are not scored
PY 2029–2030 (Years 3–4)	Pay-for-reporting	ACOs must report; scored on submission completeness, not outcomes
PY 2031+ (Year 5+)	Required and scored on performance	Full accountability for clinical outcomes

Quality Scoring (RFA §XI.C)

Quality Scoring Formula

Each quality measure earns 0–10 Quality Measure Points based on performance benchmarks. The maximum available points are: (RFA §XI.C)

Performance Years	Max Quality Measure Points	Measures Scored
PY 1–2 (2027–2028)	50 points	4 claims measures + CAHPS (eCQMs optional, not scored)
PY 3–4 (2029–2030)	70 points	4 claims + CAHPS + 2 eCQMs (pay-for-reporting: full 10 points awarded for submission)
PY 5+ (2031+)	70 points	4 claims + CAHPS + 2 eCQMs (all pay-for-performance)

The Total Quality Score is calculated as follows:

(RFA §XI.C)

The CI/SEP multiplier is applied in a graduated manner (unlike ACO REACH’s binary pass/fail). CMS will publish the specific multiplier scale in methodology papers, but the graduated approach means partial credit is possible — an ACO showing meaningful improvement earns a higher multiplier than one that is flat, even if neither hits the top threshold.

Prevention and Quality Plan (PQP) New in LEAD (RFA §XI.C.2)

The PQP is tied to quality scoring: up to 5 additional quality points in PY 2027–2028 and up to 10 in future PYs. (RFA §XI.C.2)

Prevention and Quality Plan (PQP) — Detailed Requirements

Starting in PY 2027, all LEAD ACOs must develop and implement a prevention intervention reported via the PQP. The PQP outlines the intervention each ACO will implement to drive care delivery transformation in preventive care. CMS defines preventive care on a spectrum: primary prevention (preventing chronic disease), secondary prevention (diagnosing early and intervening before clinically significant events), and tertiary prevention (improving quality of life for those with existing chronic disease). (RFA §XI)

PQP Phased Timeline

Phase	Timing	Requirements
Phase I — Goal Setting	PY 1 (2027)	Conduct a needs assessment of the aligned population. Identify prevention goals. Design the prevention intervention. Identify measures to track impact. Establish partnerships with community-based organizations. Report specific, measurable goals to CMS.
Phase II — Launch	PY 2 (2028)	Begin launching the prevention intervention. Must have a fully established intervention by end of Phase II. Actively engage beneficiaries. Identify lessons learned. Begin reporting data on beneficiary engagement, challenges, and strategies to CMS.
Phase III — Implementation	PY 3+ (2029+)	Full implementation. Submit annual reports on status, progress, milestones for beneficiary engagement, and progress on prevention measures identified in Phase II.

(RFA §XI)

ACOs are expected to design interventions that address the core needs of their specific beneficiary population. For example, an ACO primarily serving High Needs beneficiaries should design an intervention addressing High Needs. An ACO with high behavioral health prevalence should address behavioral health. ACOs serving beneficiaries with multiple needs retain flexibility in design. (RFA §XI)

Thematic Prevention Tracks (Recommended, Not Required)

CMS provides three thematic tracks ACOs can use to inform their intervention design. ACOs working outside these tracks may be asked to explain their choices with data-informed, evidence-based rationale. (RFA §XI)

1. Cardiovascular Disease / Hypertension / Cardiometabolic-Kidney Disease / Tobacco Cessation — Cardiovascular disease is the leading cause of death for Medicare recipients; smoking is the leading preventable cause of death. Prevention could focus broadly on risk reduction or narrowly on smoking cessation or hypertension control.
2. Prevention of Out-of-Home Placement / Fall Prevention — Falls are the leading cause of injury and injury-related deaths for older adults. Prevention and early treatment of falls improves quality of life and reduces spending, helping beneficiaries remain in their homes.
3. Nutrition Services — Food impacts health across numerous chronic conditions. Access to healthy food and nutrition counseling reduces spending on diet-sensitive conditions and prevents frailty.

PQP Resources and Flexibilities

ACOs can leverage multiple LEAD features to support their PQP: Benefit Enhancements (e.g., MNT expansion), Beneficiary Engagement Incentives (e.g., Chronic Disease Prevention $150 food benefit), the RISE to Age in Place falls prevention episode under CARA, partnerships with community-based organizations, and the ACCESS Model (tracks: early cardio-kidney-metabolic, cardio-kidney-metabolic, musculoskeletal, behavioral health). (RFA §XI)

ACOs that implement the CARA RISE to Age in Place falls prevention episode may satisfy the PQP requirement through that initiative. (RFA §XI.C.2)

High Performers Pool (HPP) (RFA §XI.C.4)

High Performers Pool (HPP) — Detailed Mechanics

LEAD ACOs qualify for the HPP bonus if they meet BOTH criteria: (RFA §XI.C.4)

1. Meet CI/SEP criteria (score of at least 1) OR receive both CI/SEP score of 0 AND the full PQP Reporting Adjustment
2. Have an average percentile rank of 70% or more across the quality measures

HPP Funding: The pool is funded from 50% of the quality withhold amount not earned back by ACOs that fail CI/SEP criteria. For example, if an ACO earns back 2.85% of its 3% withhold, then 50% of the remaining 0.15% contributes to the HPP. (RFA §XI.C.4)

HPP Distribution: Funds are distributed proportionally based on each qualifying ACO’s total beneficiary alignment-months relative to all qualifying ACOs’ alignment-months. This means larger qualifying ACOs receive proportionally larger HPP bonuses. The highest-performing ACOs may earn a net quality payment above their 3% withhold. (RFA §XI.C.4)