Build your CJR-X playbook with insights from Signature Medical Group’s Matt Civili on hidden episode costs, lessons from earlier models, and what to address before negotiating gain sharing.
For a hospital CFO, the question is financial: How much could we spend on care outside our walls—and can we see that exposure? For an orthopedic practice leader, it’s operational: What will the hospital ask us to take on, and how will our contribution be recognized? Both questions lead to the same challenge: building a partnership that connects financial accountability with the people making care decisions.
CJR-X begins January 1, 2028, but understanding episode costs, strengthening care-management processes, and working through hospital–physician agreements takes time. Organizations with BPCI or CJR experience have a foundation to draw on, along with assumptions worth revisiting. Those entering bundled payments for the first time need to identify where to start.
To explore those decisions, CODE Technology spoke with Matt Civili, Executive Director of Signature Medical Group, an independent, physician-owned multispecialty group serving St. Louis and Kansas City. Through Signature Care Management, its team has organized the largest clinically integrated orthopedic bundled payment program in the country—bringing experience coordinating care and managing episode costs across physician groups beyond its own practices. Matt oversees Signature’s bundled payment and value-based care initiatives and has worked through BPCI, CJR, and BPCI Advanced—from analyzing episode spending to redesigning how care is delivered.
In the following Q&A, Matt explains where internal hospital data falls short, why post-acute care deserves close attention, and how to lay the groundwork for gain-sharing agreements. His perspective gives hospital and practice leaders concrete starting points for assessing their opportunities, clarifying responsibilities, and deciding what to address first.
CJR-X at a glance
CJR-X is Medicare’s next mandatory bundled payment model for hip and knee replacement, and it starts January 1, 2028. It builds on the original CJR, but it reaches far more hospitals and follows joint replacement into the outpatient setting.
- Who’s in: Participation is mandatory for hospitals nationwide; CMS projects more than 2,500 will be required to take part. The hospital, not the surgeon’s practice, holds the risk.
- What’s covered: Inpatient and hospital outpatient hip and knee replacements. Each episode runs from the procedure through 90 days afterward and includes Part A and Part B spending: the hospital stay, physician services, and post-acute care.
- How it’s priced: Target prices are set regionally rather than from each hospital’s own history, and lower-acuity episodes are priced the same whether they happen inpatient or outpatient.
- Risk: Hospitals face two-sided risk from year one, with no phase-in. Gains and losses are capped at 20%, or 5% for rural, safety-net, and certain other protected hospitals.
- Quality: Five measures, including the hip and knee patient-reported outcome measure (PRO-PM), feed a composite quality score that affects reconciliation.
- Gain sharing: Hospitals may share savings with physicians and post-acute providers, within caps and quality requirements. Payments can’t be tied to referral volume or value.
For private practices that lived through BPCI, the headline is simple: the risk has moved to the hospital, but the surgeon still drives most of what happens in those 90 days.
What’s different about CJR-X
Q: You’ve been through BPCI, CJR, and BPCI Advanced. What is genuinely different about CJR-X?
The biggest difference is the case mix. Since the original CJR, elective joints have moved heavily into ambulatory surgery centers. That means the episodes that land in CJR-X will skew toward higher-acuity, more complicated cases, and both hospitals and physician groups are nervous about it. The inclusion of the THA/TKA patient-reported outcome measure (PRO-PM) in quality scoring is another important change.
The open question is whether regional target prices will reflect that shift. If the baseline period still captures elective episodes that have since moved to ASCs, target prices could be set too low for the case mix hospitals actually have.
Q: When will participants get their target prices?
CMS is expected to send target price information and historical data to participants sometime next year. No date has been finalized.
Q: If a hospital or practice reuses its BPCI or CJR playbook, what could mislead them?
The first step is to reassess the likely case mix. A playbook built when most episodes were elective won’t fit a population weighted toward fractures and complex cases. Fractures are especially hard: the patient is admitted without warning, so there’s no chance for a pre-op risk assessment or home study to plan post-acute placement. Patients admitted from a facility will often go back to one, but other fracture patients need a plan built on the fly.
There is no one-size-fits-all approach anymore. Market demographics and local circumstances will determine which strategy a hospital should pursue and how fast it needs to implement.
Q: Will every hospital need to make major changes?
Not necessarily. A hospital that has historically been more efficient than its peers may benefit from a regional target price inflated by inefficiencies elsewhere in the market. That’s why an early opportunity assessment is valuable: it shows whether a hospital needs significant change or is already well positioned.
Data and episode spend
Q: When you look at 90-day episode spend, what buckets do you group it into?
The buckets haven’t changed much across programs; TEAM differs mainly because of its 30-day window. Post-acute care is the focus: inpatient rehab, skilled nursing, home health, and outpatient PT. CJR-X will push hospitals to move away from protocol-driven discharge (rehab, then a SNF from a list, then home health) toward individualized post-acute plans for each patient.
Q: Where do you get the data? No one wants to wait for Medicare to hand it over.
Medicare makes claims data available, (The Standard Analytic Files), but it isn’t cheap. The data arrives raw and beneficiary-blinded: essentially every paid claim. It takes a skilled analyst to turn it into episodes. At Signature, it takes our analyst a few weeks to build and validate every joint episode from a performance year into 90-day episodes, with every charge tied to each beneficiary. That shows the range of what was spent and where.
Q: Hospitals have a lot of their own data. What’s missing if they rely only on internal systems?
Hospitals will know the procedure cost, their DRG payment, where patients were discharged, and sometimes how long they stayed. What they’ll miss is Part B services billed elsewhere during the 90 days. If a patient had another Part B procedure at an outside provider, those charges count against the bundle, but the hospital can’t see them.
Q: Do most hospitals have access to post-acute data?
It depends on the system. Data from a hospital-owned SNF, inpatient rehab unit, or home health agency is generally easier to get. Community facilities may be less willing to share data, particularly when the hospital operates competing post-acute services.
Care redesign
Q: Where should hospitals focus to succeed?
Supply chain is often the first place hospitals look for savings, but experience in BPCI and CJR shows those efforts only go so far. The big dollars are in how patients move through the episode, especially post-acute care.
Many firms, including accounting firms with existing hospital relationships, are offering risk assessments and data processing. What they typically lack is care-redesign experience. Hospitals will get the most value from either hiring someone internally with value-based care experience to own the program or partnering with a consultant who has done care redesign before.
Q: What was the single most effective tactic in the earlier models?
A concierge-style relationship between the patient and a care manager or nurse navigator for the full 90 days. That person becomes the patient’s point of contact and checks in at key touch points, guiding them on what they should or shouldn’t be doing. They also help educate patients on additional services during the 90 day post op period that may not be medically beneficiary. Pairing those care managers closely with discharge staff was one of the most effective things Signature did.
Q: What technology are hospitals using to manage episodes?
Most will use their EHR, even though EHRs handle episodic management poorly, because clinicians don’t want to double-document. Dedicated care-management platforms that integrate with the EHR (Signature’s CareMosaic is one) can pull patient demographics over an interface and track post-acute care without duplicate entry.
Gain sharing and reconciliation
Q: What are gain-sharing arrangements looking like so far?
They’re all over the board, and they’ll be market-specific. A key factor is the share of episodes done by non-employed community surgeons. Structures under discussion include:
- Episodic fees: A practice that only does on-call fracture cases at a hospital may prefer a flat per-episode payment for helping manage the post-acute portion, rather than taking on risk.
- Upside/downside arrangements: More likely where the practice does a larger share of the hospital’s episodes, including elective HOPD cases.
- Physician-owned hospital incentives: A physician-owned hospital may incentivize its own surgeons who participate in care redesign activities.
- Extending existing agreements: One group plans to expand its current ACO shared-savings agreement with a health system to cover CJR-X episodes on the same terms.
Q: How does reconciliation work between the practice and the hospital? Do you wait for CMS?
Get the gain-sharing agreement in place early, well before the first reconciliation, because a lot of review and setup has to happen first. The recommended sequence is an opportunity assessment of the hospital’s overall upside and downside, then a look at individual surgeons and groups, then the agreement.
Matt also recommends a neutral third party that has access to the hospital’s data to validate and calculate the gain share. That party reports which episodes qualified, the results, how the agreement terms apply, and what the group or physician should be paid when savings arrive. Both sides get the same report, so the practice and the hospital are comfortable with the results.
Q: Can a hospital manage CJR-X without physician partners?
It’s harder in a 90-day bundle than in TEAM’s 30-day bundle, because the longer window gives physicians more leverage. The surgeon writes the post-acute orders and carries the liability. A surgeon could send patients to their own PT for three weeks and then to outpatient therapy, and the hospital is at risk for all of it.
Case managers can help, and hospitals can use privileging, but they generally can’t override physician preferences. High-volume surgeons may have greater negotiating leverage, including the option to move cases to another facility if the terms aren’t attractive. Hospitals where most episodes are done by employed physicians or hospitalists will have an easier time.
The private practice perspective
Q: How motivated are private practices to help hospitals with CJR-X?
They should be motivated, because the risk has shifted off their backs. Under BPCI, the practice’s TIN was at risk and it had to persuade the hospital to cooperate. Now the hospital owns the risk and needs the practice more than before. A practice can go in with an upside-only mindset. If it’s already doing much of the episode management work, it makes sense to negotiate to get paid for it.
Independent practices seem to be getting more comfortable with hospitals taking on the financial risk under CJR-X. Upside-only gain sharing can help offset cuts, such as a 2.5% payment reduction, and working together beats constant conflict.
Q: Which organizations are moving first?
Physician-owned hospitals. They will own the risk directly, so they’ve been the most proactive in asking questions.
Q: Could CJR-X change where practices do their Medicare joints?
Possibly. If a practice can negotiate a gain-sharing agreement, it could move some Medicare cases from its ASC back to the hospital outpatient department. Those cases would then count in the program and share in savings, and ASC capacity would open up for commercial volume. In the right markets that makes sense, and the HOPD can be the right site of care for some patients.
Looking ahead
Q: Could ASCs eventually be included in CJR-X?
It’s a possibility worth watching. The proposed rule included comments about future ASC inclusion, and the model currently has no end date. Including standalone ASCs would be a logistical challenge for CMS, so hospital-owned ASCs may come first. Many independent surgeons operate in hospital-owned surgery centers, so early engagement could pay off later.
Q: Why is demand for CJR-X help slow right now?
Many organizations see CJR-X as far down the road and aren’t yet willing to pay for help. Matt expects that to change as TEAM hospitals that took Track 1 go at risk in January and realize they need support. TEAM involves less clinical care redesign because of its 30-day window, but the same data and care-management needs apply.
Have questions as you work through CJR-X planning?
Get in touch with CODE Technology. For more detail on participation, financial accountability, and quality measures, explore our CJR-X guide.
