In a new experimental program, Medicare soon will pay participating doctors to provide better preventive care for frail older adults and younger people with disabilities. Among the initiatives, it will encourage greater support aimed at avoiding falls.

The program, called Long-term Enhanced ACO Design, or LEAD, is an important step toward encouraging medical providers to help prevent falls before they happen. This would be a major, positive change for a medical system that normally focuses on treating injuries from falls after they occur.

But there is a paradox here. Yes, LEAD could use Medicare to reduce falls. But at the same time, the White House is aggressively moving to limit existing falls prevention efforts under Medicaid and the Older Americans Act, the government’s umbrella funding source for most senior services.

The Value Of Falls Prevention

Preventing falls can be a big deal for older adults, who often suffer significant injury and cognitive damage after even minor falls.

While reducing these events would cost relatively little, it could significantly reduce health care spending.

Imagine two situations. In one, Medicare pays for bathroom grab bars, help rearranging furniture and rugs, and maybe for a cane or walker—all before a fall. Now imagine none of those preventive steps. Instead, an older adult slips in the shower and fractures a hip, then needs surgery, a multi-day hospital stay, and an admission to a skilled nursing facility for weeks of rehab.

By spending perhaps $1,000 on these services, Medicare could save tens of thousands in medical costs, to say nothing of improving the well-being of that senior.

How LEAD Will Work

LEAD, which was announced in late December, is scheduled to begin in January, 2027 though, as with many Trump Administration initiatives, the initial proposal leaves many key details unresolved. The demonstration is due to last for 10 years, a long time for one of these experiments.

The effort will go well beyond falls prevention. It is the latest version of a decades-long CMS effort to convince physicians to participate in what generally are described as Accountable Care Organizations. This model lives under a broad umbrella of value-based care that applies to physicians who are paid through traditional Medicare, rather than Medicare Advantage. But in some ways these initiatives are an effort to make fee-for-service medicine look more like managed care.

ACOs, including the LEAD update, have two key features:

First, Medicare pays a fixed amount for an episode of care, rather than paying for each individual procedure. For example, it pays a single set price for everything it takes to repair that fractured hip, rather than paying separately for each x-ray, surgery, bandage, and physical therapy visit.

Second, Medicare pays extra to docs who provide high-quality care at a cost below a benchmark price while withholding some payments from physicians who fail to meet those targets.

LEAD is CMS’s latest attempt to sell reluctant providers, including smaller and rural practices, on the benefits of ACOs. For example, it promises more predictable payments and less paperwork than earlier versions.

A Step In The Right Direction

But what is most valuable to older adults and people with disabilities is LEAD ’s focus on high-need patients, including those who are dually eligible for Medicare and Medicaid and struggle to leave their homes.

LEAD is an important step in the right direction, but also reflects the Trump’s Administration’s inconsistent attitude towards federal programs for older adults, including those to prevent falls.

Even as LEAD would use Medicare dollars to encourage doctors to help patients avoid falls, the Administration has been cutting other federal falls prevention programs.

Inconsistent Policy

For example, it proposed slashing by two-thirds a falls prevention program funded under the Older Americans Act. In the end, Congress rebuffed Trump’s proposed cuts and held funding at the same $7.5 million level it has been for the past two years.

Similarly, the White House proposed freezing funding for senior nutrition programs under the OAA, even though food costs are rising substantially. The result will be longer waiting lists for Meals on Wheels and similar programs even though malnutrition is a significant cause of falls among older adults.

At the same time, at the request of the White House, the GOP-controlled Congress cut Medicaid by $1 trillion over the next decade, though it is the main federal program that provides long-term supports and services to low-income older adults and younger people with disabilities.

Medicaid, which mostly is provided through private managed care insurance, already should be providing preventive care and addressing the risk of falls before they occur.

Now, those Medicaid cuts, first enacted in last summer’s big budget bill, are likely to result in reductions in home and community-based care programs, many of which also may help reduce falls.

Now, in the name of preventing fraud, the Trump Administration is moving to cut off hundreds of millions of dollars more in Medicaid funding to Minnesota, and reportedly is targeting states such as New York and California as well. This too could lead to more falls, more hospitalizations, and more Medicare spending.

Will There Be A Net Benefit?    

There is a certain logic to shifting falls prevention to Medicare. It is the federal program that would benefit most from any cost savings generated by fewer falls and it covers far more people than Medicaid (though perhaps fewer than the Older Americans Act). But many of these efforts fit better in the world of social services than health care and don’t come instinctively to doctors or hospitals.

In effect, the Administration would shift resources from non-Medicare programs that work relatively well to an experimental program with an uncertain future.

It is not possible to know how many medical practices will enroll in LEAD, which is optional, or how many will stick with it. It is even tougher to predict whether any will take advantage of the incentives aimed at preventing falls by vulnerable patients or whether those efforts will succeed.

Give CMS credit for thinking about how Medicare can help high-risk beneficiaries and specifically how to encourage docs to help them avoid falls. But will this step achieve its goals. And if it does, will it make up for the non-Medicare benefits the Trump Administration wants to cut?