In late September, the CMS Innovation Center released final evaluation reports for two bundled payment models that shaped orthopedic care over the past decade: the Comprehensive Care for Joint Replacement (CJR) Model and the Bundled Payments for Care Improvement Advanced (BPCI-A) Model. Combined, the models produced close to $1B in savings for Medicare. Both models reduced spending and maintained quality of care, and the reports describe how participants achieved those results.
These findings matter now because CMS cited CJR's results as support for CJR-X, the mandatory nationwide joint replacement model that begins January 1, 2028. CMS also said lessons from both models have been applied to TEAM (Transforming Episode Accountability Model), which launched January 1, 2026. Below is a summary of each report and what it means for hospitals preparing for these models.
CJR: $180M in Savings Over Performance Years 6–8
The final CJR evaluation covers performance years (PYs) 6-8 (October 2021 through December 2024); prior performance years 1-4 had produced $72M in savings (not statistically significant), but these savings were wiped out in PY5 during the COVID-19 Public Health Emergency, during which the model produced $95M in losses primarily due to a relief policy that waived downside risk. In PYs 6-8, the model included 321 hospitals in 34 metropolitan statistical areas and more than 143,000 lower extremity joint replacements, covering approximately 9% of these procedures nationally. 66% of these CJR procedures were performed in outpatient settings, compared with 71% nationally.
Key results from the report included:
- $180M in net Medicare savings, made up of a $136M estimated reduction in joint replacement spending and $44M in net reconciliation amounts.
- 28% fewer discharges to inpatient rehabilitation facilities (IRFs) and a 32% increase in patients discharged home with home health.
- $443 reduction in per-episode IRF spending for elective procedures.
- No adverse changes in quality across four claims-based measures: complications, mortality, unplanned readmissions, and emergency department use. CJR hospitals and comparison hospitals both reduced unplanned readmissions and complications by more than 25% from the baseline period.
The report also describes what CJR hospitals did differently across the episode. Before surgery, they increased patient education, physical therapy, and patient optimization. During the hospital stay, they prioritized early ambulation, physical therapy, and pain management. After discharge, they sent more patients home, sent fewer to IRFs, and started following up with patients after they left the hospital. The evaluators describe early discharge planning built around a "why not home" approach.
BPCI-A: $800M in Net Savings Over Eight Years
BPCI-A was a voluntary model that ran from October 2018 through December 2025. Over its eight model years, it included 1,103 hospitals (about one in three eligible hospitals), 871 physician group practices, and 1.8M patients. Participants chose from more than 30 clinical episodes across eight service lines.
Findings from that report demonstrated:
- About $800M in net Medicare savings across eight model years; the model lost money in model years 1 through 3, but design changes in model year 4 (2021) produced savings that offset those early losses.
- $700 to $1,100 lower spending per episode in each model year compared with similar non-participating providers.
- No effect on readmission or mortality rates, and patient-reported functional status changed at similar rates for participants and comparison patients.
- Room to improve in shared decision-making: Most patients reported positive care experiences, but a small share said hospital staff did not account for their preferences for post-discharge care.
As with CJR, participants reduced spending mainly by using CMS data to understand their post-acute care use and sending fewer patients to post-acute facilities. CMS said BPCI-A did not meet the Innovation Center's criteria for expansion, but that its lessons are being carried into TEAM.
What the Two Reports Have in Common
Most of the savings in both models came from the same place: fewer patients discharged to institutional post-acute care and more patients recovering at home. That shift depended on work that must take place outside the hospital: patients had to be prepared before surgery, discharge plans had to be set early, and someone had to stay in contact with patients after they went home. As a result, spending fell while quality remained steady.
Both experiences support CMS’s move away from fee-for-service Medicare, with its lack of aligned incentives for high-value care across different clinicians and settings, toward value-based episode-based care. CJR-X, the very first mandatory nationwide episode-based payment model, begins for thousands of hospitals in January 2028.
What Changes Under CJR-X
CJR-X builds on CJR but includes several differences that affect how hospitals should read these results.
First, CJR-X is mandatory nationwide. CJR covered about 9% of joint replacements, whereas CJR-X applies to nearly every IPPS/OPPS hospital (excluding those in TEAM and those in Maryland), including many with no bundled payment experience whatsoever. A recently released CJR-X participant list includes more than 2,200 hospitals. This list will grow to nearly 3,000 hospitals in 2031 once TEAM ends.
Second, quality affects CJR-X payment more directly. The CJR evaluation measured quality primarily through claims-based outcomes, while CJR-X will use a composite quality score (CQS) that includes the total hip/knee arthroplasty patient-reported outcome-based performance measure (THA/TKA PRO-PM), which requires matched PROMs before surgery and one year after, as well as a number of risk and matching variables. Moreover, the CQS in CJR-X directly impacts participating hospitals’ discount factor, playing a more direct and impactful role on reconciliation outcomes.
Equally important, some of the easier savings in CJR-X are already taken. As a result of learnings from CJR and BPCI-A, many programs have already reduced their post-acute utilization of IRF and SNF. Hospitals that have already made that shift will need to find savings in other parts of the episode, such as avoidable ED visits and readmissions, making it more challenging to meet target prices. In addition, like the later years of CJR, CJR-X includes outpatient hip and knee procedures; programs that have already moved most appropriate patients to outpatient have less potential post-acute savings to pursue, and the patients who remain inpatient tend to be more complex and therefore more costly to manage.
What CJR-X Hospitals Should Do
The evaluations identify specific activities that drove results. Each one is something a program can put in place before January 2028:
- Pre-op education and optimization: CJR hospitals increased patient education and optimization before surgery. Patients who know what to expect and are prepared for recovery at home are more likely to be discharged home, including same-day discharge when appropriate.
- Setting discharge expectations early: A "why not home" approach starts at the first pre-op visit, not on the day of discharge.
- Follow-up after discharge: CJR hospitals started contacting patients after they went home. Remote monitoring and two-way messaging enable care teams to find problems early and keep a patient out of the ED when an office visit or phone call will do.
- Including patient preferences in discharge decisions: The BPCI-A evaluation found some patients felt their preferences for post-discharge care were not considered. Structured education and check-ins give patients a way to raise concerns before decisions are made and help them understand the reasoning behind discharge planning, improving patient satisfaction (which is also a component of CQS in CJR-X).
- PROMs collection: CJR-X adds the THA/TKA PRO-PM to the quality score. Programs need a reliable way to collect matched pre-op and one-year PROMs without adding staff or burdening existing staff with manual work. Hospitals that still collect PROMs on paper and by phone have a clear opportunity for improving spend, care efficiency, and patient experience by automating this process.
Force Therapeutics was designed and built for high-value episodic care. Our partner hospitals use our platform for risk stratification and prehabilitation, condition- and procedure-specific education before and after surgery, remote monitoring and messaging during recovery, and automated collection of PROMs, regardless of whether procedures are inpatient or outpatient.
To learn more about how hospitals using Force are already ready for CJR-X, contact the Force team below:
