The American Hospital Association is urging CMS to make the proposed Comprehensive Care for Joint Replacement Expanded (CJR-X) model voluntary, warning that mandatory nationwide participation would impose unsustainable financial and operational burdens on hospitals — particularly safety-net, rural and sole-community providers.
CMS in April proposed CJR-X as a mandatory, nationwide episode-based payment model set to begin Oct. 1, 2027. Under the model, most acute care hospitals would be financially accountable for the cost and quality of hip, knee and ankle replacements across a 90-day episode of care.
The AHA argues in a June 9 comment letter addressed to CMS Administrator Mehmet Oz, MD, that creating a voluntary pathway to participation would “provide a stronger foundation for success, giving organizations the flexibility to build needed capabilities and progress toward achieving savings and improved patient outcomes.”
Voluntary participation is particularly important because hospitals currently face the “competing demands of multiple mandatory” Center for Medicare and Medicaid Innovation models, the AHA said.
Health systems juggling multiple mandatory payment models face compounding administrative strain, the AHA said, as each program brings its own rules, reporting demands and compliance requirements. Running parallel models also makes it harder for both hospitals and CMS to isolate which interventions are actually driving results.
The AHA also cited MedPAC’s March 2026 report showing aggregate Medicare inpatient margins of negative 12.1% in FY 2024 as evidence that many hospitals cannot absorb the infrastructure investments CJR-X would require.
The organization’s analysis of fiscal 2023 to 2025 Medicare claims data found that hospitals serving higher proportions of dual-eligible and low-income subsidy patients consistently landed in the highest-spending quintile under the model’s pricing methodology.
The AHA is also asking CMS to treat year one as a data-sharing period only, followed by at least two years with no downside risk. It also wants the agency to eliminate any discount factor, extend the rebasing period to no more than once every 10 years, raise the low-volume threshold above the proposed 31-case floor and cap stop-loss limits at 10% for most participants and 2.5% for safety-net hospitals.
CMS was accepting comments on the proposed rule through June 10 and is expected to issue a final rule later this year.
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