CJR-X (Comprehensive Care for Joint Replacement Expanded) Model

Background

Lower extremity joint replacements (LEJR) are among the most frequent surgeries for people with Medicare. In Original Medicare’s fee-for-service (FFS) payment system, providers and suppliers are paid separately for an LEJR surgery and any subsequent services in the recovery period. This may lead to fragmented care, duplicated use of resources, and avoidable utilization, leaving patients feeling unsupported and at greater risk of post-operative complications and avoidable health care expenditures.

Aims

By holding participating hospitals responsible for care and spending during the LEJR procedure and after discharge, the CJR-X Model would encourage hospitals to:

• Work as a team with physicians and post-acute care providers to support patients and ensure optimal outcomes;
• Coordinate care across settings, especially care transitions, from the initial hospitalization or outpatient procedure through recovery; and
• Produce high value care by reducing unnecessary or duplicative services, such as avoidable hospital readmissions.

Innovation

CJR-X would be the first nationwide test of a mandatory episode-based payment model. The CJR Model, which ended on December 31, 2024, was tested in 34 Metropolitan Statistical Areas (MSAs). The most recent evaluation of performance years 6 and 7 (2021-2023) showed that the CJR Model produced an estimated $112.7 million in net savings in while maintaining quality of care.  

Design

CJR-X would test an episode-based payment approach in which acute care hospitals participating in the model are assessed against a target price that assumes all costs associated with an LEJR episode of care, beginning with the procedure and ending 90 days following discharge from the inpatient hospitalization or outpatient procedure. With few exceptions, the episode would include all related items and services paid under Medicare Part A and Part B for eligible CJR-X patients—such as the cost of the procedure, hospital stay, post-discharge physical therapy, and follow-up visits.

All providers and suppliers furnishing LEJR care to patients would continue to be paid under existing Medicare payment systems. Following the end of a model performance year, actual total spending for the episode would be compared to the participant hospital’s target price and, depending on quality and spending performance, the hospital could receive an additional payment from Medicare or be required to repay a portion of the episode spending.

Most hospitals paid under the Inpatient Prospective Payment System (IPPS) would be required to participate in CJR-X. Certain hospitals would be exempt, including those participating in the Transforming Episode Accountability Model (TEAM), located in Maryland, and those not paid under both the IPPS and Outpatient Prospective Payment System (OPPS).

How does CJR-X differ from the Transforming Episode Accountability Model (TEAM)?

While TEAM tests a similar episode-based payment approach to CJR-X, it also includes care for non-LEJR procedures, such as heart surgery and spinal fusion. Additionally, the episode length in TEAM is 30 days, as opposed to 90 days in CJR-X. The two models could produce an evidence base that CMS could use to compare outcomes based on episode length.

How does CJR-X improve on the CJR Model?

CJR-X would apply a risk adjustment methodology that is low on administrative burden but better accounts for “acuity” so that hospitals are not penalized for beneficiaries who are complex or for whom care is unpredictably complicated.

Will hospitals be required to participate in both CJR-X and TEAM?

Hospitals participating in TEAM would be excluded from CJR-X. When TEAM ends, eligible hospitals would be required to participate in CJR-X.

Which procedures are included in CJR-X?

A CJR-X episode is defined by the admission of an eligible Medicare fee-for-service beneficiary to a hospital paid under the Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS) that eventually results in a discharge or claim paid under:

• MS-DRG 469 - Major Hip and Knee Joint Replacement or Reattachment of Lower Extremity with Major Complications or Comorbidities (MCC) or Total Ankle Replacement
• MS-DRG 470 - Major Hip and Knee Joint Replacement or Reattachment of Lower Extremity without MCC
• MS-DRG 521 - Hip Replacement with Principal Diagnosis of Hip Fracture with MCC
• MS-DRG 522 - Hip Replacement with Principal Diagnosis of Hip Fracture without MCC 
• HCPCS 27447 – Total Knee Arthroplasty
• HCPCS 27130 – Total Hip Arthroplasty

How will CJR-X address quality?

Here are some ways the CJR-X Model might improve quality:

• The model would utilize a quality first principle, meaning hospitals must achieve a minimum level of episode quality, as determined by a hospital’s composite quality score, before receiving reconciliation payments. The composite quality score reflects hospital performance and improvement in the following five measures: 
  • Hospital-Level Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) measure (Centers for Medicare & Medicaid Services Measures Inventory Tool (CMIT) ID# 350);
  • Hospital Visits within 7 days of Hospital Outpatient Department (HOPD) Surgery (CMIT ID #344, OP-36);
  • Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey measure (CMIT ID #338);
  • Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems Survey (OAS CAHPS) (CMIT ID #162); and
  • Hospital-Level Total Hip and/or Total Knee Arthroplasty (THA/TKA) Patient-Reported Outcome-Based Performance Measure (PRO-PM) (CMIT ID #1618). 
• The model would incentivize hospitals to avoid expensive and harmful events that increase episode spending and reduce the opportunity for reconciliation payments.
• CMS would provide additional tools to improve the effectiveness of care coordination by participant hospitals including:
  • Providing hospitals with relevant spending and utilization data;
  • Waiving certain Medicare requirements to encourage flexibility in the delivery of care; and
  • Creating and sharing resources to support successful participation. 

How will CJR-X protect safety net and rural hospitals?

The CJR-X Model would apply a 5% stop loss to hospitals with a high proportion of dually eligible Medicare and Medicaid patients, “geographically rural” hospitals that do not necessarily fit the statutory definition of a rural hospital, Medicare-dependent, small rural hospitals, and Sole Community Hospitals. CJR-X would also adopt a robust risk adjustment methodology that uses 29 risk adjusters compared to 3 in the CJR Model. At the participant level, CMS would risk adjust by hospital bed count and for provision of care to a high percentage of dually eligible beneficiaries. At the episode-level, CMS would adjust for age, number of chronic conditions (as determined by Hierarchical Condition Category [HCC] count), whether a beneficiary was dually eligible for Medicare and Medicaid, procedure type, disability as the original reason for Medicare enrollment, prior PAC use, and 21 specific HCCs. Notably, these are the same 29 risk adjusters used in TEAM. Critical access hospitals and rural emergency hospitals would be exempt from CJR-X because they are not paid under both the IPPS and OPPS. 

• IPPS Proposed Rule
• Press Release: IPPS Proposed Rule
• CJR Model webpage