CMS finalized the Comprehensive Care for Joint Replacement Expanded model July 31, and the agency’s participant list now names 2,217 hospitals on the hook for hip, knee and ankle replacement episodes through 90 days after discharge starting in 2028. The original CJR model covered about 465 hospitals in 67 metro areas.
Ninety days reaches well past the point where most hospitals stop watching, and CMS is banking on it. The agency projects $736 million in savings over the first five years, roughly seven times what the original model returned across its 2016-2024 run.
The reach is uneven. Texas alone accounts for 275 participating hospitals, followed by California with 168 and Florida with 127; the top five states carry 35% of the list. Washington, D.C. has one. Maryland has none, excluded because it operates under the state’s Total Cost of Care Model, and Rhode Island is the only other state without a participating hospital.
Being on the list is the easy part. What value-based care asks of a hospital has been changing for a while.
“Early on when value-based care started, it was a payment model that was introduced by the payers or by CMS that created a new revenue stream other than fee for service,” said Daniel Marino, a principal at ECG Management Consultants who has advised more than 250 provider organizations on value-based strategy and managed care contracting.
“Over the last year, year and a half, it’s sort of flipped … we’ve moved from that payment model to more of an operating model around value-based care,” he said. “Organizations are taking a very strategic approach around what are those capabilities that they need to build and optimize in order to be successful in these new payment models and being able to take on risk.”
A payment model lives in the finance department. An operating model has to reach into how care actually gets delivered, and that is where hospitals are thinnest. Asked which capability systems struggle with most, Mr. Marino named analytics. The organizations succeeding “have shifted from reactive care to more prospective care,” he said — ranking patients by risk, spotting the ones trending worse and reaching them before they escalate.
“The biggest challenge that organizations have is just getting the data and really making sense of the data in such a way that they could then begin to operationalize that around some level of interventions or programs,” Mr. Marino said.
No single source closes the gap
Hospitals reach for clinical and billing data first, because it can be easiest to find, but neither gets a risk-bearing organization all the way to an answer. Claims data fills in the care a patient received elsewhere, and still stops short of explaining it.
“I often say the claims data tells you what’s going on, but doesn’t tell you why it’s happening,” Mr. Marino said. “That’s where the clinical data is introduced and important to the care plan.”
Social determinant data is the newest addition, capturing the circumstances around the patient rather than the patient alone. The work is less about acquiring any one source than reconciling what each can and cannot tell you.
The old bundle priced the surgery plus about 30 days of recovery, the same window TEAM has used since it began Jan. 1. Under CJR-X, the episode starts with the pre-operative picture, including utilization history and social circumstances, and runs through recovery and the handoff to ambulatory management, which pulls specialists into a cost equation most have sat outside.
“The specialists have the highest influence when you think about managing the total cost of care,” Mr. Marino said. “And it’s not necessarily what the surgeon does in the procedure room or even what’s occurring within the operating room, but it’s all the elements that are wrapped around it.”
Those elements are where hospitals have the least infrastructure, and the clearest example sits at the front of the episode. Every hospital runs pre-surgical testing, but it is built to clear a patient for the operating room, not to anticipate what happens after they leave it and during recovery. A patient cleared for surgery can still be discharged into a home that cannot support recovery resulting in a visit to the emergency room, and under a 90-day episode that becomes the hospital’s problem.
“If you’re not properly evaluating the home environment of the patient and even the caregiver and the caregiver’s ability to take care of the patient … when the patient is discharged to the home environment, that’s where they run into problems,” Mr. Marino said. The problems surface within days, he said, at the emergency department.
Checking the home environment and the caregiver’s capacity before surgery lets a hospital line up support in advance, which “comes in way under what that cost structure is when you compare it to the ED rates or the readmission rates,” he said.
CJR-X does not begin until Jan. 1, 2028, and the agency already pushed it back three months once. For the 2,217 hospitals on the participant list, CJR-X follows TEAM in January and the Ambulatory Specialty Model in the physician fee schedule. Different names, different specialties, but the capability all three require is the same: a hospital that can see its own population, reach the patients trending worse and understand what a patient is going home to will carry that into whatever comes next.
