Comprehensive Care for Joint Replacement – Expanded (CJR-X): Summary and Key Differences from the Original CJR Model

What is the CJR-X Model

CJR-X is CMS’s proposed national expansion of the original CJR Model, which ran from April 2016 through December 2024. The original CJR Model met the requirements for nationwide expansion (reduced spending while maintaining quality), and the CMS Chief Actuary has certified it for mandatory national rollout. CJR-X is the vehicle for that rollout.

CJR-X is a mandatory bundled payment model for hip, knee and (inpatient) ankle joint replacement episodes. Hospitals are held financially accountable for the cost and quality of care from admission/procedure through 90 days post-discharge.

Core Mechanics of CJR-X at-a-Glance

Element	CJR-X Proposal
Start date	October 1, 2027 (PY1: Oct 1, 2027 – Sep 30, 2028)
Performance year cycle	Fiscal year (Oct–Sep)
Participant	All eligible acute care hospitals nationwide — paid under both IPPS (Inpatient Prospective Payment System) and OPPS (Outpatient Prospective Payment System)
Episode trigger	MS-DRG 469, 470, 521, 522 (inpatient) or HCPCS 27130, 27447 (outpatient)
Episode duration	Anchor admission/procedure + 90 days post-discharge
Pricing baseline	3-year baseline, regional benchmark, with prospective trend + normalization + discount factors and risk adjustment multipliers
Discount factor	2.0% (adjustable down based on quality)
Stop-loss / stop-gain	20% for most hospitals; 5% for rural hospitals, Medicare-Dependent Hospitals (MDHs), Sole Community Hospitals (SCHs) and safety net hospitals
Quality measures	5 measures across complications, patient experience and PROs
Quality-payment alignment	Composite Quality Score (CQS, 0–20 points) categorizes hospitals into Excellent / Good / Acceptable / Below Acceptable

Key Differences Between CJR-X and CJR

1. Geographic Scope — The Biggest Change

• Original CJR: Mandatory only in 67 selected Metropolitan Statistical Areas (MSAs), – later reduced to 34; rest of country was opt-in or excluded
• CJR-X: Mandatory nationwide for all eligible acute care hospitals in 50 states, DC, and U.S. Territories — except hospitals already in TEAM (Transforming Episode Accountability Model), plus Maryland (which has its own all-payer model)

2. Performance Year Calendar

• Original CJR: Calendar year (Jan–Dec)
• CJR-X: Fiscal year (Oct–Sep) — aligns with IPPS rulemaking cycle

3. Outpatient Episodes Are Fully Integrated

• Original CJR: Inpatient-focused (started before outpatient TKA/THA were common)
• CJR-X: Explicitly designed for the reality that nearly 75% of THA/TKA episodes are now outpatient. Adds outpatient HCPCS codes (27130, 27447) as direct episode triggers and pulls in two new outpatient quality measures (Hospital Visits Within 7 Days of Hospital Outpatient Department (HOPD) Surgery; Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS)).

4. Discount Factor Reduced

• Original CJR: 3.0% discount factor (Medicare’s share of expected savings)
• CJR-X: 2.0% discount factor — CMS acknowledges LEJR (Lower Extremity Joint Replacement) spending has already declined since 2016 and there’s less room for additional savings

5. THA/TKA PRO-PM Is Now Mandatory and Integrated

• Original CJR: PRO data submission was voluntary with bonus quality points for participating
• CJR-X: PRO data submission is mandatory via the Hospital IQR Program (effective July 1, 2025); CJR-X pulls THA/TKA PRO-PM data directly from IQR — no separate submission. The PRO measure is also weighted more heavily than in original CJR.

6. CJR-X Quality Measures Explained (vs. the Original CJR)

Domain	Original CJR	CJR-X
Complications	THA/TKA Complications (RSCR)	THA/TKA Complications (inpatient) Hospital Visits Within 7 Days of HOPD Surgery (outpatient)
Patient Experience	HCAHPS	HCAHPS (inpatient) OAS CAHPS (outpatient)
PROs	THA/TKA PRO (voluntary, bonus only)	THA/TKA PRO-PM (mandatory, weighted)

The CQS now includes separate inpatient and outpatient sub-composites that combine based on each hospital’s inpatient/outpatient episode mix.

7. No Quality Improvement Points

• Original CJR: Awarded extra points for 2-decile-or-more improvement vs. prior year
• CJR-X: No improvement points. CMS explicitly chose absolute-achievement scoring only, citing that improvement points may reflect random variation or case-mix changes. This also aligns with TEAM’s approach.

8. Safety Net Hospital Protections Added

• Original CJR: Standard stop-loss applied; safety net hospitals were disproportionately likely to owe repayments
• CJR-X: 5% stop-loss for safety net hospitals (in addition to existing 5% protection for rural, MDH, SCH). This is a new protection responding to CJR evaluation findings.

9. Risk Adjustment Is More Sophisticated

• Original CJR: Limited risk adjustment in early years; added in 2021 extension
• CJR-X: Comprehensive risk adjustment from day one: age group, HCC count, beneficiary economic risk, prior post-acute use, disability status, 22 binary variables for recent medical history (180-day lookback), plus hospital-level adjusters for bed size and safety net status

10. Low Volume Hospital Policy Changed

• Original CJR: Low-volume hospitals (<20 episodes) initially got 100% regional target prices, later removed entirely
• CJR-X: Hospitals with <31 LEJR episodes per year are excluded from reconciliation for that year — no target price, no upside and no downside. The threshold rolls forward annually so hospitals can re-enter as volume changes.

11. Same-Day Surgery + Inpatient Conversion Rule

• CJR-X (new): If a hospital performs an outpatient LEJR and then admits the patient as inpatient within 3 days, the episode begins on the outpatient procedure date (not the inpatient admission date). This closes a loophole and aligns episode attribution with clinical reality.

12. Excluded Hospital Types

• Original CJR: Excluded based on geography
• CJR-X explicitly excludes:
  • Hospitals not paid under both IPPS and OPPS (rules out Indian Health Service, Tribal hospitals)
  • Critical Access Hospitals
  • Rural Emergency Hospitals
  • Rural Community Hospital Demonstration participants
  • Hospitals participating in TEAM (no double-counting)
  • Maryland hospitals (TCOC Model)

13. ASCs Considered But Excluded

CMS considered including Ambulatory Surgery Centers (ASCs) but did not incorporate them into the proposed model in order to maintain alignment with the original CJR structure. Future rulemaking may revisit this decision.

Quality Score → Payment Mechanics

CQS Range	Category	Effective Discount	Eligible for Reconciliation Payment?
≥ 17.1	Excellent	0.0%	Yes
12.1 – 17.0	Good	1.0%	Yes
6.1 – 12.0	Acceptable	2.0% (full)	Yes
≤ 6.0	Below Acceptable	2.0% (full)	No — ineligible for upside even if under target price

This is an important structural change. Each hospital receives a Composite Quality Score (CQS) ranging from 0 to 20 points based on performance across five measures. The resulting score determines both eligibility for reconciliation payments and the applicable discount.

Critical implication: A hospital with poor PRO-PM capture rates that loses a measure score risks dropping into “Below Acceptable,” which forfeits all upside reconciliation payments while still owing full repayment if over target. This has more significant financial implications than the original CJR.

CJR-X Readiness: What Hospitals Should Evaluate Now

CJR-X reflects CMS’s decision to move joint replacement bundled payments beyond a limited model and into broader, nationwide application. It builds on the original CJR Model and incorporates several updates that align with how care is currently delivered and measured.

The proposal also highlights several broader policy directions:

• Patient-reported outcomes (PROs) are incorporated as a core component of performance measurement
• Outpatient procedures are included alongside inpatient care within episode accountability
• Additional protections are included for safety net and rural hospitals
• Quality performance has a more direct impact on financial outcomes

Nearly all acute care hospitals nationwide not participating in TEAM will fall under CJR-X. By October 2027, these sites will need to capture high-quality THA/TKA PRO data across both inpatient and outpatient settings.

Key Takeaways

• CJR-X expands bundled payments nationwide
• PRO-PM is now mandatory and directly tied to payment
• Outpatient episodes are fully integrated
• Quality performance determines financial upside and risk
• Hospitals must prepare for 2027 now