CMS finalized the Comprehensive Care for Joint Replacement Expanded Model, or CJR-X, on July 31, requiring most acute care hospitals nationwide to take on financial accountability for the cost and quality of hip, knee and ankle replacement episodes beginning Jan. 1, 2028.
CMS points to the original CJR model’s record of generating savings while maintaining quality as the rationale for expanding the model nationwide. However, physicians are divided on what a mandatory model means for patient care, financial risk and consolidation. Three orthopedic surgeons joined Becker’s to share their outlook.
Editor’s note: Responses have been lightly edited for clarity and length.
Question: Do you think this program will actually increase patient care quality — or will it disproportionately hurt hospitals that have fewer post-acute care options and less financial cushion to absorb penalties for mistakes?
Steve Schutzer, MD. Orthopedic Surgeon and Co-founder of Upswing Health (Stamford, Conn.): I’m bullish on CJR-X. Hospitals have had years to prepare, and CMMI is giving them yet another year’s notice. The model is a proven cost-containment solution. To be successful, it forces collaboration across stakeholders and breaks down silos. I don’t see any downside to it at all. I do understand the unique challenges of rural and underserved community hospitals. But I think CMMI will get it right. Rural hospitals have certain advantages, too. They’re smaller, more nimble, more flexible — oftentimes not constrained by the bureaucracy of large health systems.
Ugo Ihekweazu, MD. Orthopedic Surgeon at Texas Orthopedic Hospital (Houston): Bundled payment models can improve joint replacement care by encouraging coordination and eliminating unnecessary utilization. Prior CJR experience has shown that savings can be achieved while maintaining quality.
My concern is avoiding a “race to the bottom.” Earlier bundled models demonstrated the challenges of continually changing and lowering target prices, particularly for hospitals that had already made significant gains in efficiency. At some point, further reductions in spending may come at the expense of the resources necessary to deliver high-quality care.
That concern is amplified with a mandatory nationwide model. Hospitals differ significantly in patient complexity, post-acute resources and their ability to absorb financial risk. If those differences aren’t adequately accounted for, the model could disproportionately penalize hospitals caring for more vulnerable populations.
I support the transition toward value-based arthroplasty care, but the goal should be sustainable efficiency and better outcomes, not simply making each episode progressively cheaper. CJR-X will ultimately succeed if it rewards high-quality, efficient care while preserving access and avoiding incentives to select healthier patients.
Sean Bak, MD. Orthopedic Surgeon at Motor City Orthopedics (Novi, Mich.): CJR-X aims to improve coordination of care, and if we accept its metrics as adequate proxies for quality, it may also improve measured quality. However, this mandatory program is occurring on a much broader scale than CJR and will therefore have further-reaching effects than CJR did.
The experience with CJR suggests that bundled payments can reduce spending, particularly by changing post-acute utilization, but the demonstration of quality improvement was mixed. The question with CJR-X is whether we are going to reward true improvements in value or disproportionately reward systems that already have the infrastructure and resources to manage the post-acute episode. Systems with stronger post-acute infrastructure will have an inherent advantage over those without it, which could fuel further point-of-care consolidation rather than meaningful coordination.
Another concern is whether a 90-day episode adequately captures what we are trying to accomplish with joint replacement. The real goal is durable pain relief, function, implant survivorship and quality of life — not simply a favorable first 90 days. We need to be careful that short-term cost pressures, now so broadly applied, do not discourage investment in implants, technologies and techniques that may increase costs today but produce better long-term outcomes. This will also undoubtedly increase the outmigration of joint replacement to ambulatory surgery centers, which may be appropriate, but there will be increasing burden on the inpatient side to care for higher-acuity patients.
CJR-X may ultimately create greater value — from CMS’ perspective — through lower spending and better coordination, but the cost of that higher value on the CMS side will be borne by the higher unquantified administrative burden and financial pressure on the systems actually delivering the care.
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