The Comprehensive Care for Joint Replacement (CJR) model saved Medicare $180 million in its final three performance years without changing care quality, according to the program’s final evaluation released Sept. 24.
CMS launched CJR in 2016 as its first mandatory bundled payment program, requiring hospitals in randomly selected cities to take financial responsibility for hip and knee replacements and the 90 days after discharge. Hospitals could earn a payment from CMS or owe money back depending on whether episode spending came in under or over a target price. The model ended in December 2024.
The final report covered the three years after CMS extended and reworked the model (October 2021 through December 2024). During that stretch, 321 hospitals across 34 metro areas performed about 143,000 joint replacements that counted toward the model, which was about 9% of all hospital-based joint replacements in the U.S. CMS had narrowed the model to higher-spending markets, so CJR patients tended to be somewhat older and sicker than joint replacement patients nationwide.
Researchers compared how spending and quality changed from a baseline period to the extension years at CJR hospitals versus a randomized control group, then estimated net savings to Medicare. The report drew on claims data, surveys, interviews and site visits.
Seven things to know:
- Of the $180 million in savings, $136 million came from lower joint replacement spending and $44 million came from the net flow of payments between Medicare and hospitals, largely repayments from hospitals whose spending ran above their target prices. The model’s first five years resulted in overall losses to Medicare, according to earlier evaluations.
- Nearly all of the savings came from planned surgeries. Compared with control hospitals, CJR hospitals cut total episode payments for elective joint replacements by $1,226 per episode, and researchers found no reduction in episode payments for joint replacements following a hip fracture.
- CJR hospitals sent fewer patients to inpatient rehabilitation facilities, lowering rehab facility spending by an estimated $443 per episode. The report found a 28% drop in rehab facility discharges and a 32% rise in patients going home with home health services. Hospitals told evaluators they prepared patients for recovery before surgery, set expectations early that patients would go home, started discharge planning sooner and coordinated more closely across care settings.
- Evaluators found no differences in key quality outcomes between CJR and control hospitals. Readmissions, complications and deaths declined at both groups of hospitals, tracking national trends, with readmission and complication rates falling more than 25% from baseline. Emergency department visits rose slightly in both groups, with no meaningful gap between them.
- About 66% of CJR procedures were performed in outpatient settings, compared with 71% nationally. By the time the model ended, outpatient care was the main setting for both hip and knee replacements at CJR and control hospitals.
- Researchers and hospital leaders were split on the model’s success in interviews with Becker’s earlier this year. Some researchers said the savings were small and came almost entirely from cutting post-acute care, and that later changes to how CMS set target prices penalized safety-net hospitals at higher rates. Some health systems said the model made them better at managing episodes of care overall, and that the patient education, care coordination and post-discharge follow-up they built under CJR carried over into TEAM, a mandatory, five-year Medicare payment model that launched in January.
- CMS has said it is using the results from CJR to support a nationwide expansion. The mandatory Comprehensive Care for Joint Replacement Expanded (CJR-X) model launches in 2028 and will apply to most hospitals across the country. Hospitals currently in the TEAM model are exempt until that program concludes at the end of 2030, and they will then join CJR-X the following year. Hospitals will face both upside and downside financial risk from the first day, and CMS projects the model will save Medicare $736 million over its first five years.
