A New Performance Reality for ACO Leaders

By Rhonda Quintana

Published Jan. 6, 2026

Patients are receiving letters from CMS about GUIDE, they’re coming to your office and they want answers. Are you ready?

The launch of CMS’s GUIDE (Guiding an Improved Dementia Experience) Model sends a clear signal: dementia is a Medicare priority.

For years, dementia has quietly driven disproportionate utilization, caregiver strain, and downstream medical costs—often without a care model designed to address the realities of cognitive decline and caregiver dependence. GUIDE represents CMS’s most direct attempt to acknowledge that gap and establish a national framework for dementia care.

GUIDE describes the “what.” It does not give ACOs direction into the “how,” creating a challenge for organizations that were never intended to operationalize it.

GUIDE Is Not an Operational Decision for Many ACOs

For a significant number of ACOs, GUIDE is not a model they can—or should—deploy themselves.

Applications to participate are closed. Running GUIDE internally would conflict with existing billing and care management structures. And even absent those constraints, GUIDE represents a fundamentally different operating model than most organizations are built to run.

In other words, for many ACOs, GUIDE is not an execution choice. Yet GUIDE is already present. CMS letters are reaching Medicare beneficiaries. Caregivers are asking questions. New payments and care activities are being introduced for individuals who already sit within ACO populations.

The care delivery may occur externally. The performance implications do not.

The Structural Tension GUIDE Introduces

Most value-based care models are built on a familiar premise: organizations influence care delivery, measure outcomes, and manage performance accordingly. GUIDE disrupts that dynamic.

Under the model, Medicare beneficiaries may enroll in dementia care programs independent of ACO workflows. The ACO does not initiate enrollment, manage the care model or control execution quality. Yet dementia-related utilization and outcomes remain highly relevant to overall performance.

This tension represents a significant leadership challenge: external execution coupled with internal performance exposure.

Why “Waiting” Is Not a Strategic Choice

Faced with uncertainty, many organizations adopt a wait-and-see posture. With a model as new and complex as GUIDE, that instinct is understandable. But waiting is not neutral.

Medicare beneficiaries will still enroll. Payments will still occur. Dementia will remain among the most expensive and least predictable conditions in Medicare.

Absent visibility, measurement, or deliberate governance, organizations risk reacting to outcomes after the fact rather than shaping how this new reality shows up in their performance.

Accountability as a Governance Decision

GUIDE reflects a broader shift in value-based care: the emergence of programs that organizations do not directly operate, but that nonetheless influence outcomes they are accountable for.

The critical leadership question is not:

• whether the model is well-intentioned, or
  
  
• whether an organization can run it internally
  
  

The more relevant question is:

How should organizations respond when external programs meaningfully intersect with their performance?

Accountability does not always require ownership.  But it does require intentionality—visibility into what is occurring, clarity around outcomes and alignment on performance expectations. GUIDE makes that distinction unavoidable.

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A Signal of What Comes Next

Dementia is just the beginning. As CMS continues to move faster than traditional operating models, leaders will increasingly encounter programs that challenge conventional assumptions about control, responsibility and performance.

In that sense, GUIDE is a test case. Not of policy design but of leadership maturity within value-based care.

The organizations that navigate this moment effectively will not be those with the strongest opinions, but those willing to separate operations from accountability and respond with deliberation rather than discomfort.

GUIDE is here. And accountability, whether acknowledged explicitly or not, remains a choice.

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