With the Comprehensive Care for Joint Replacement Expanded (CJR-X) model finalized by CMS, virtually all acute care hospitals in the country will be accountable for the cost and quality of 90-day lower extremity joint replacement (LEJR) episodes of care. For the vast majority of orthopedic programs, this is uncharted territory.
To help orthopedic leaders make sense of what's ahead, Becker’s Hospital Review and Force Therapeutics recently hosted a roundtable with two leaders and orthopedic surgeons from the American Association of Hip and Knee Surgeons (AAHKS) Advocacy Committee: Dr. Max Courtney and Dr. Steve Engstrom. Between them, they bring more than two decades of combined experience with BPCI, BPCI Advanced, commercial bundles, and CMS advisory and advocacy work.
Below are some key takeaways from the conversation. The complete recording of the session can be found here.
CJR-X at a Glance: Cost and Quality Both Count
Unlike most past CMS bundles, CJR-X is mandatory nationwide, with exceptions for hospitals already participating in TEAM and those in Maryland. A tension inherent in CJR-X, according to Dr. Engstrom, is that the hospital holds financial accountability for the episode, even though surgeons drive most of the outcomes. This is where gainsharing arrangements come into play; hospitals that are not coordinating and providing incentives for surgeons and their teams to work toward optimal outcomes will find it very difficult to influence behavior.
Episodes are triggered by the lower extremity joint replacement DRGs, which now include hip fractures, as well as the CPT codes for total hip and total knee arthroplasty performed in the hospital outpatient setting. Each hospital receives a target price for the full 90-day episode, and CMS guarantees its savings with a 2% discount.
What truly sets CJR-X apart from the original CJR is the comprehensive quality component. As Dr. Engstrom explained, hospitals receive a composite quality score on a 0–20 scale. Scoring above 6 is required to be eligible for a reconciliation payment, and scoring above 12 reduces the discount applied to the target price.
“The takehome is it’s both a financial and a quality-based metric for a bundle.”
— Dr. Steve Engstrom
Many Hospitals Aren't Ready, and Some Design Choices Raise Concerns
Dr. Courtney was direct: he doesn't believe most hospitals are prepared for CJR-X. His take was that the Transforming Episode Accountability Model (TEAM) covers roughly a quarter of the country and only recently began in January 2026, the original CJR was limited to a set of metropolitan areas, and BPCI and BPCI Advanced were voluntary. So while hospitals in former CJR markets will have a bit of a head start, many others have about a year and a half to build capabilities they've never actually needed.
Both surgeons flagged design concerns. For instance, because ASCs are excluded, the model may create incentives that run counter to the shift toward outpatient joint replacement, and it could encourage "cherry picking and lemon dropping," with healthier patients steered to one setting and higher-risk patients concentrated in another. The inclusion of hip fractures adds another layer of complexity, particularly for tertiary centers that accept complex transfers. Dr. Engstrom advised administrators to bring their trauma surgeons into CJR-X planning now, not just the arthroplasty team.
Both surgeons also noted that hospitals aren't explicitly required to share savings with surgeons, even though surgeon offices (nurses, schedulers, and medical assistants) absorb much of the work of keeping patients on track at home and out of the emergency department.
Where Variation Emerges: Post-Acute Care, Readmissions, and Implants
Asked where cost variation is greatest, Dr. Engstrom pointed to two questions every program should answer first: What is our length of stay? and what share of our patients use post-acute care? If routine total joints are still crossing into inpatient stays, or a high percentage of patients are discharged to skilled nursing facilities (SNF) or rely heavily on home health, that's where episode costs will diverge. Once those are addressed, implant pricing becomes the next lever to examine.
Dr. Courtney added that many programs have already captured the early gains from reducing length of stay and SNF use since the early BPCI years. What remains is the long tail of costly complications. A single readmission for a periprosthetic infection or fracture, he noted, “will take you fifty joint replacements to dig yourself out of.”
Regional Pricing: "Not Designed to Be Won"
CJR-X target prices are built from regional data, and hospitals are compared with regional peers on absolute performance rather than rewarded for year-over-year improvement. Dr. Courtney noted that CMS regions are broad, so a rural or safety-net hospital may be benchmarked against large urban systems. CJR-X does add risk adjustment, including for dual-eligible patients, and a lower downside cap for safety-net hospitals, but whether those adjustments capture the true cost of care won't be clear until reconciliation results arrive.
On this point, Dr. Engstrom offered one of the session's most memorable highlights:
“These are not programs that are designed to be won ever. They are programs to drive everybody toward the mean, eliminate outliers, and ultimately reduce spending year over year.”
— Dr. Steve Engstrom
The Quality Score Is Low-Hanging Fruit, and PROMs Are the Hard Part
For programs with strong clinical results that still underperform financially, both surgeons pointed to the composite quality score (CQS) as a likely culprit. Its components include the hip and knee complication rate, hospital visits within seven days of outpatient surgery, patient experience surveys, and the THA/TKA PRO-PM, which requires matched pre-op and one-year PROMs and, as Dr. Courtney noted, measures improvement against substantial clinical benefit (SCB) rather than the minimal clinically important difference (MCID), with the former representing a more challenging improvement threshold.
Both surgeons specifically highlighted the importance of PROMs:
"You can be providing super high quality care, efficient care, and low cost care. And if you're just not set up to collect patient reported outcomes in the manner that CMS wants, you're going to struggle in this bundle."
— Dr. Steve Engstrom
While academic centers often collect PROMs in isolated instances for research, most other hospitals, regardless of how excellent their care may be, do not.
Don't Underestimate the Staffing Lift
Asked what hospitals are most likely to underestimate, Dr. Engstrom pointed to non-clinical resources. During the original BPCI, he recalled a department of five joint replacement surgeons that needed four full-time staff just to run the bundle–and this was before PROMs were part of the picture. He expects that need could double or triple under CJR-X. Dr. Courtney shared that his practice relied on seven full-time nurse navigators across its bundled programs.
The flip side, Dr. Engstrom cautioned, is overconfidence: high-efficiency hospitals shouldn't overestimate how much they can earn, given CMS's willingness to lower target prices over time and the inherent design of the program, which is intended to save money for CMS.
What AAHKS Asked CMS For
During the comment period, AAHKS urged CMS to slow down, arguing that most hospitals aren't prepared for the level of risk in a mandatory bundle, that excluding ASCs would undermine the model, and that the lack of a convening role for physicians or mandatory gainsharing could accelerate consolidation. While CMS moved the start date forward to January 1, 2028 and lifted the gainsharing caps from the original CJR, most of the other recommendations from AAHKS were not adopted in the final rule.
Where to Invest Before January 2028
With limited resources, both surgeons pointed to the same two priorities:
- Front-load the episode with care coordination: Shift post-op work into the pre-op period. A nurse coordinator or navigator can set expectations about going home after surgery, address fears about nursing facilities, and give patients a number to call if something goes wrong, so that a draining wound becomes an office visit rather than an ER readmission. With the right set of digital tools, a single navigator can replicate this effectively for hundreds of patients.
- Build a reliable PROMs system. Pre-op surveys are easiest to capture while the patient is in the clinic. The one-year follow-up is the hardest, especially for rural patients who don't want to drive back for a visit when they're doing well. Without multiple dedicated FTEs, Dr. Courtney said, programs need a patient engagement platform that reaches patients outside the clinic.
From the Audience Q&A
- Will ASCs be pulled in? Both surgeons expect ASCs to be included in future value-based models. For now, site-of-service decisions will depend on employment structure, hospital–surgeon relationships, and gainsharing arrangements.
- What about low-volume programs? Programs near the 31-episode threshold face a tough calculation, since the cost of added staff may exceed any reconciliation payment. Consolidating cases within a health system or shifting eligible cases to an ASC may be viable strategies.
- Will commercial and Medicare Advantage payers follow? Many already have. Unlike CJR-X, those bundles are negotiated and often reward moving appropriate patients to lower-cost sites of service.
- What should a skeptical surgeon do? Dr. Engstrom shared the skepticism but urged surgeons to engage now, while financial risk in the early years is relatively low, because future iterations of the model are likely to carry more.
What You Should Do Now
The panel closed with advice that applies to every program: know your numbers. Understand your readmission rate, PROMs compliance rate, and HCAHPS performance before your first target price arrives. And recognize that CJR-X, like the models before it, is here to stay.
For orthopedic leaders, the path forward comes down to extending care beyond the four walls without adding staff: preparing patients before surgery, engaging them through recovery, catching issues before they become readmissions, and capturing matched PROMs at the pre-op and one-year intervals required by CMS. That's exactly what Force Therapeutics was built for across inpatient, outpatient, and ASC settings.
Our sincere thank you to Dr. Courtney and Dr. Engstrom for sharing their time and expertise. Watch the full on-demand recording here.
To learn more about how leading institutions across the country are using Force to prepare for CJR-X, reach out to the Force team below:
