The LEAD Model—Kidney Care’s Value-Based Care Journey LEADs Here

Key Benefits for Kidney Care Providers:

• Chronic Kidney Disease (“CKD”) and End-Stage Renal Disease (“ESRD”) patients are part of standard ACO populations, rather than being set apart in a separate model
• 10-year duration with no benchmark rebasing
• High-needs patient support and flexibility
• Non-Primary Care Capitation (“NPCC”) to pay nephrologists or dialysis providers a flat monthly rate
• CMS-Administered Risk Arrangements (“CARA”) episode bundles for defined kidney care episodes
• Integration of Medicaid dual-eligible coordination in select states

A Continuous Value-Based Kidney Care Journey

For the last decade, nephrology practices have navigated kidney care focused Center for Medicare and Medicaid Innovation (“Innovation Center”) models—from ESRD Seamless Care Organizations (“ESCOs”) under the Comprehensive ESRD Care (“CEC”) Model (2015–2021) to today’s Kidney Care Choices (“KCC”) Model (2022–2027). With KCC sunsetting at the end of 2027, The Long-term Enhanced ACO Design (“LEAD”) Model offers kidney care providers the long‑term stability needed to sustain value‑based care for CKD and ESRD patients. As detailed in our article, CMS Bets on the Long Game with 10‑Year LEAD ACO Model, CMS released the Request for Applications (“RFA”) on March 31, 2026, and ACOs must apply by May 17, 2026 to join the first performance year starting January 1, 2027.

Opportunities for Nephrology in LEAD

LEAD’s design creates meaningful opportunities for nephrologists to lead or strategically partner in ACOs, particularly for patient populations with complex kidney needs. One of LEAD’s most important features for kidney care is its high‑needs flexibility, as an ACO in which more than 40% of attributed patients qualify as complex—such as ESRD patients, frail beneficiaries or dual eligibles—may operate at a smaller minimum size. This flexibility makes nephrology‑led ACOs viable with fewer attributed lives, lowering the barrier to entry for kidney‑focused organizations.

Equally notable is LEAD’s long‑term horizon. The model’s ten‑year benchmark stability gives ACOs the certainty they need to justify long-term investments and recoup costs that may take years to yield savings, such as home dialysis expansion, transplant optimization and robust CKD care‑coordination programs. The longer time frame aligns more closely with the way kidney care investments develop and deliver value.

LEAD also introduces new payment and care‑delivery tools that reward proactive kidney care. Through the Nephrology‑Primary Care Collaborative (“NPCC”), an ACO can pay a nephrology group or dialysis provider a prospective, per‑patient amount to manage kidney care. This structure supports intensive upstream interventions—such as CKD education, medication optimization, care navigation and remote monitoring—without the distortions of fee‑for‑service volume incentives. In addition, CARA episodes allow nephrologists to share in savings tied to improved outcomes for defined care episodes, such as planned dialysis starts or post‑transplant management, with CMS providing the underlying data, benchmarking and reconciliation infrastructure.

Taken together, these features create durable financial upside for kidney specialists tied directly to quality, outcomes and cost‑effective care—positioning nephrology as a central driver of value‑based performance under LEAD.

The CEC-KCC-LEAD Evolution

The CEC Model from 2015 to 2021 was the first specialty‑focused ACO framework. Under CEC, dialysis clinics and nephrologists formed ESCOs to manage ESRD patients on dialysis. The model reduced hospitalizations and improved dialysis‑related care, but it ultimately increased costs to Medicare. Nearly a 2% reduction in gross spending was more than offset by incentive payments. The key lesson from CEC is that specialty ACOs can improve clinical outcomes, but their financial structures must be designed to produce net savings from the outset.

CMS launched the KCC Model in 2022 with two tracks. Kidney Care First paid nephrologists capitated amounts to manage patients with CKD Stages 4 and 5 and dialysis, along with a $15,000 kidney transplant bonus. Comprehensive Kidney Care Contracting (“CKCC”) created Kidney Contracting Entities that assumed accountability for total cost of care under risk‑sharing arrangements. CKCC required nephrologists and transplant centers to participate as partners, offered multiple risk tracks ranging from graduated to full global risk, and used separate spending benchmarks for CKD and ESRD phases. These goals mirrored prior models by focusing on delaying progression to ESRD, promoting planned dialysis starts and home dialysis, and increasing transplant rates.

KCC’s results were mixed but informative. CMS’s initial evaluation found no significant Medicare savings in the first performance year, though clinical indicators were encouraging. Optimal dialysis starts increased by 16% under CKCC, home dialysis utilization rose between 22% and 32%, and transplant wait‑listing improved by 15% percent. In response, the Innovation Center reduced CKD capitation payments, ended the transplant bonus after 2025 and sunset the Kidney Care First track due to low participation and financial losses. KCC was extended through December 2027 to allow for an orderly transition. The takeaway is clear—clinical improvements alone are not sufficient and nephrology providers must incorporate financial sustainability into their participation strategies from the start.

As the era of kidney-specific Innovation Center models winds down, a broader total-cost-of-care approach is emerging in its place. The LEAD Model, launching January 2027, incorporates many features that kidney care providers have sought:

• Stable, Long-Term Benchmarks: LEAD’s ten‑year period running from 2027 through 2036, with no rebasing, allows an ACO to invest in CKD care management, home dialysis programs and transplant coordination without concern that early savings will reset future benchmarks. This was a major flaw in both CEC and KCC, where annual success often reduced future earning potential. Under LEAD, a nephrology‑driven ACO that lowers costs through better care can benefit from those improvements over a full decade.
  • Next Step: Model projected savings over a ten‑year horizon to justify upfront investments in care redesign that shorter‑term models could not realistically support.
• Managing CKD/ESRD Patients Within General ACOs: LEAD treats CKD and ESRD patients as part of the standard ACO population, eliminating the need for separate renal ACO models. The model adjusts for higher costs through concurrent risk adjustment and separate trend factors. Critically, if an ACO’s population exceeds 40% high-needs patients, it can operate with a much smaller panel than the standard 5,000 minimum—potentially as few as 1,000-1,500 aligned beneficiaries. This echoes the High Needs ACO concept from REACH/KCC, now embedded across LEAD.
  • Next Step: Assess your patient panel’s high-needs percentage immediately—if it exceeds 40%, you may be able to form a viable nephrology-led ACO with a far smaller patient base than previously required.
• Payment and Risk-Sharing Innovations:  One of the most important tools for nephrology that LEAD offers is Non‑Primary Care Capitation, or NPCC. NPCC allows a LEAD ACO to pay specialty providers, such as a nephrology practice or a dialysis company, a fixed monthly amount per patient for all covered services, without later reconciliation to fee‑for‑service claims. Participation in NPCC is voluntary and negotiated directly between the ACO and the provider. A nephrology group could agree to receive a set amount per CKD Stage 4 or 5 patient in exchange for managing all nephrology care, giving the practice flexibility and accountability to care for those patients in a more holistic way through office visits, telehealth, education and care coordination. In a similar fashion, an ACO could use NPCC to pay a dialysis provider a prospective amount for each aligned dialysis patient, adding accountability for clinical outcomes and hospital utilization. Because NPCC shifts financial risk to the specialist, it creates a strong incentive for nephrologists and dialysis providers to focus on proactive care that keeps patients healthier and reduces avoidable hospitalizations. These arrangements are supported by fraud and abuse waivers that permit innovative payment structures, building on the same protections that enabled gainsharing under CEC and KCC and will continue to apply under LEAD.
  • Next Step: Evaluate pros and cons of capitation payments versus fee-for-service and the degree of related financial risk.
• Specialist Gainsharing via CARA: LEAD’s CMS‑Administered Risk Arrangements, or CARA, allow ACOs to implement gainsharing arrangements with specialists and episode‑based payment bundles directly relevant to kidney care. Under LEAD, an ACO could, for example, structure care episodes focused on the transition from CKD to ESRD during the first 90 days of dialysis, dialysis access placement and post‑surgical care, or kidney transplant care covering hospitalization and post‑acute services. In these arrangements, specialists and the ACO agree on target budgets and share in savings or losses, with CMS administering the reconciliation process. CMS has indicated that CARA will include standardized episode definitions for CKD and ESRD beginning in 2028.
  • Next Step: Begin identifying highest‑cost episodes now, such as unplanned dialysis starts, vascular access complications or transplant‑related readmissions, and develop target budgets and care protocols so you are prepared to propose CARA arrangements once the model is available.
• Dual-Eligible Integration: Many ESRD patients are dually eligible for both Medicare and Medicaid, which has historically resulted in fragmented funding and gaps in care coordination. LEAD introduces a built‑in Medicare‑Medicaid integration pilot in two states that allows ACOs to better align care for dual‑eligible patients. This includes coordinating long‑term services, home health support for dialysis patients and addressing social drivers of health such as transportation and access barriers. Neither CEC nor KCC included a comparable integration mechanism.
  • Next Step: Evaluate the percentage of dual‑eligible patients in your population and engage state Medicaid agencies early. Understanding the timing and structure of the integration pilot can help position a practice or ACO to participate and take advantage of these alignment opportunities as LEAD is implemented.

The table at the end of this article summarizes key differences and similarities among the CEC Model, KCC’s CKCC track and the new LEAD Model from a nephrology perspective.

Challenges for Nephrology Providers

LEAD is not designed exclusively around kidney care, which means nephrology outcomes will not always be the sole focus of performance measurement. However, the quality metrics are broad and include common CKD and ESRD co-morbidity areas that nephrologists regularly address such as diabetes management and blood pressure control, as well as patient experience. As a result, nephrology practices participating in LEAD will want to focus on championing kidney‑specific priorities internally, such as increasing transplant referrals or expanding home dialysis, even where those goals are not expressly tied to LEAD’s core metrics.

LEAD also differs from KCC in its payment structure. The model does not include a direct transplant bonus or CKD‑specific capitation payment. It places greater importance on how nephrology practices negotiate internal incentive structures, whether through NPCC arrangements or episode‑based payments, to encourage appropriate CKD management and transplant‑oriented care.

For dialysis providers, particularly those operating joint venture clinics, LEAD may introduce meaningful financial tension. Improvements that benefit patients and reduce total cost of care, such as higher home dialysis utilization or increased transplant rates, may also reduce in‑center volumes. This dynamic underscores the need to carefully align economic incentives across physician groups, dialysis operators and ACO partners.

On the compliance front, LEAD continues the fraud‑and‑abuse waivers available under prior CMS models. These waivers allow ACOs to share savings and fund patient‑focused interventions, such as reducing dialysis‑related cost sharing or providing nutrition and care‑management support, when structured appropriately. Used thoughtfully, these tools can support better kidney outcomes while remaining compliant.

Early planning matters. Nephrology groups should begin engaging potential ACO partners now, design NPCC or episode‑based agreements that balance clinical and financial incentives, and ensure their data and reporting infrastructure can meet LEAD’s requirements. Those who plan early will be better positioned to manage both the opportunities and tradeoffs that LEAD presents.

Seizing the Future

LEAD represents a paradigm shift. Instead of carving out kidney patients into separate models, it invites nephrologists to help lead within a broader, integrated ACO structure. Kidney specialists weighing their next move face several important considerations:

• Assess Your Current State: KCC will conclude in 2027 with no guaranteed successor kidney model. LEAD starts in 2027 and runs for a decade. LEAD is the intended transition path if you are in CKCC, MSSP or ACO REACH.
  • Next Steps: Nephrology groups should determine whether to apply as a LEAD ACO (applications due May 17, 2026) or partner with another ACO that will apply. The application window is finite, and early applicants will have the strongest negotiating position.
• Consider Forming or Joining a LEAD ACO: Nephrology groups who previously operated a KCE should strongly consider forming their own LEAD ACO with a broader provider network or negotiating to join an existing ACO under a structure that preserves economic and governance influence. Options may include participating as a Participant Provider with shared savings and losses along with governance rights, or as a Preferred Provider through contractual arrangements such as NPCC or CARA without full ACO membership.
  • Next Steps:Nephrology groups should move early with a concrete proposal. For example, prepare a term sheet that clearly defines the NPCC rate required on a per‑patient basis for CKD and ESRD populations, identifies the CARA episodes they are best positioned to manage, and specifies the governance, reporting and data‑access rights they require. Bringing a proposal to prospective ACO partners in advance of the May 17, 2026, application deadline helps ensure entry into LEAD with clear, enforceable contractual terms rather than informal or open‑ended commitments.
• Leverage LEAD’s Flexibilities to Continue Kidney Care Innovation: Nephrology providers have the opportunity to leverage LEAD’s added flexibility to continue advancing kidney care innovation and carry forward the most effective practices developed under CEC and KCC. KCC participants significantly increased home dialysis utilization, which correlated with fewer hospitalizations and improved care transitions.
  • Next Steps: Nephrologists should build on their progress under CEC and KCC by developing dedicated home dialysis programs and more structured CKD care management clinics under the LEAD model. LEAD’s technology enables resources and the upfront payments available for high‑cost populations—including the 1.5% advance payment—can support telehealth monitoring, home dialysis training and proactive CKD education. Practices should also establish clear internal performance goals, such as achieving home dialysis rates of 30% or more, to promote accountability and sustained improvement.
• Home Dialysis & CKD Care Management: KCC demonstrated that scaling home dialysis and structured CKD programs can materially reduce downstream utilization. In a LEAD ACO, nephrology groups should formalize these efforts through dedicated home dialysis pathways and CKD clinics that intervene earlier and more consistently.
  • Next Steps: Nephrology practices should use LEAD’s available upfront funding and technology to invest in remote monitoring, patient education and care coordination infrastructure that would not be economically viable under shorter‑term models.
• Transplant Promotion: Although KCC’s transplant bonus has been eliminated, LEAD’s 10‑year duration provides the financial runway necessary to capture the long‑term savings associated with successful transplantation. Each transplant avoids multiple years of dialysis costs that accrue within the LEAD performance period.
  • Next Steps: Nephrology groups should consider formal transplant referral protocols with defined timeframes, such as referral within 90 days of a CKD stage 5 diagnosis. Internal gainsharing arrangements with transplant centers tied to wait‑listing and transplant completion rates can help reinforce these goals, particularly when paired with coordination among cardiologists and endocrinologists on pre‑transplant optimization.
• Address Social Determinants of Health to Support Patients: Many interventions that improve kidney outcomes fall outside traditional FFS coverage, including nutritional support, transportation to dialysis, and behavioral health services. LEAD allows ACOs to use Part B beneficiary incentive waivers to address these needs through Chronic Disease Rewards.
  • Next Steps: Nephrology practices should screen ESRD and advanced CKD patients for social determinants of health within the first six months of LEAD participation and then develop targeted interventions such as meal delivery, ride‑sharing partnerships or integrated mental health services. These initiatives should be incorporated into the ACO’s financial planning and tied to measurable outcomes, including reductions in emergency department visits and inpatient admissions.

While careful stewardship is required to ensure kidney patients remain a clear focus within a general ACO, this challenge presents an opportunity to distinguish their needs through strong, data-driven leadership. Nephrology leaders should clearly demonstrate that ESRD patients represent some of the highest cost beneficiaries in the ACO population and that targeted nephrology interventions, such as volume management, vascular access planning and patient education, directly reduce avoidable admissions. CARA arrangements offer a practical way to quantify this value and convert it into shared savings that support continued investment in kidney‑focused programs.

Conclusion and Next Steps for Kidney Care Providers

As CMS’s kidney‑specific models wind down, the LEAD Model has emerged as a prime platform for value‑based kidney care in Medicare. Nephrology practices and dialysis organizations should engage now—not merely as participants, but as active partners shaping care delivery and financial strategy. This requires forming strong alliances with primary care groups and hospitals, negotiating payment structures that appropriately reward kidney expertise, and building the data infrastructure needed to demonstrate performance.

Immediate priorities include: (i) determining whether to apply directly to LEAD or partner with an ACO planning to apply by the May 17, 2026 deadline, (ii) auditing CEC and KCC performance data to identify what worked and where costs exceeded expectations, and (iii) preparing NPCC and CARA term sheets in advance of negotiations. Practices should also evaluate the ACCESS Model launching in mid‑2026 as a complementary, no‑downside‑risk opportunity focused on earlier‑stage CKD care.

LEAD offers nephrologists a powerful platform to carry forward—and meaningfully amplify—the clinical gains realized under CEC and KCC into a durable, integrated care model. LEAD creates the opportunity to establish a decade‑long approach that aligns financial incentives with the outcomes nephrology teams are uniquely positioned to deliver. With early planning, deliberate negotiation and disciplined investment, providers can not only succeed within LEAD but also play a defining role in shaping the future of kidney care in Medicare.

Key CMS Resources—LEAD Model

For clients who want to go directly to CMS sources, the most useful publicly available documents are:

• LEAD Model Request for Applications (RFA) (PDF)
• LEAD Application Submission Portal
• LEAD Model Application Checklist (PDF)
• LEAD Model Payment Factsheet (PDF)
• LEAD Model Overview Factsheet (PDF)
• LEAD Model Value Factsheet (PDF)
• LEAD Model Overview Webinar Slides (PDF)
• LEAD Model Overview Webinar Transcript
• CMS‑Administered Risk Arrangements (CARA) Factsheet (PDF)
  

The Benesch Healthcare team monitors developments related to the LEAD Model and other CMMI initiatives and may provide additional updates as they become available. Please contact the authors of this article for additional information or if you have any questions.

Table: Comparing the CEC Model, KCC’s CKCC track and the LEAD Model from a nephrology perspective. Key differentiators include model scale, population scope and financial incentives.

Source: CMS Innovation Center.