CJR-X Builds on an Established Approach to Bundled Payments
Beginning January 2028, CMS will launch a nationwide, mandatory bundled payments model for the first time. The Comprehensive Care for Joint Replacement Expanded (CJR-X) Model, an expansion of the recently concluded Comprehensive Care for Joint Replacement (CJR) Model, will hold more than 2,000 acute care hospitals nationwide accountable for the cost and quality of inpatient and outpatient lower extremity joint replacement (LEJR) episodes. Episodes will span the initial LEJR procedure and all Medicare spending in the 90 days following the procedure, including post-acute care. CJR-X reflects CMS’ continued interest in bundled payments as a tool for managing high-volume surgical episodes. The model builds on infrastructure developed over nearly a decade, from the CJR Model through the Transforming Episode Accountability Model (TEAM). CJR-X will launch with broad mandatory participation from the outset, spanning the majority of Inpatient/Outpatient Prospective Payment System (IPPS/OPPS)-paid hospitals nationwide.
For hospitals newly accountable under CJR-X, this history offers a practical benefit; CMS has refined its approach to episode pricing and quality measurement, and the data already indicate where hospitals will need to focus.
CJR-X’s Operational Playbook Centers on Four Strategies
Four operational strategies can help hospitals prepare to manage the cost and quality of the 90-day post-discharge period:
- Shift to lower-cost post-acute care (PAC) settings
- Reduce inpatient readmissions
- Reduce skilled nursing facility (SNF) length of stay
- Shift eligible episodes to the outpatient setting
These strategies reflect an approach CMS has encouraged across its episode-based models, and CJR-X’s 90-day episode window adds weight to each one. A longer episode window means more cumulative exposure to PAC spending, readmissions, and SNF utilization. Because CJR-X applies specifically to LEJR, hospitals evaluating the inpatient/outpatient site of care strategies for orthopedic episodes will face added pressure to shift procedures to lower-cost outpatient settings where clinically appropriate.
Post-Acute Spending Is a Sizable Share of Total Episode Spending
The 90-day window drives episode performance under CJR-X, and historical data show the importance of managing spend in this period. Between 2022 and 2024, post-procedure spending in the 90-day episode averaged $9,800 per episode, or roughly 44% of total episode spending. This spending occurs outside the hospital’s four walls, so it is critical that hospitals build networks of high-quality post-acute care partners.
A 90-day window also means more settings of care can touch a single episode, as patients move between SNF, home health agency (HHA), and outpatient rehabilitation over the course of one episode. Coordinating across that many settings calls for a broader view of the post-acute network, beyond a single preferred SNF or HHA relationship. The longer window also captures a wider range of readmission risk, including later-stage deconditioning and medication complications that can surface well after a traditional discharge. Extending care management further into the post-discharge period could help hospitals manage that risk.
Preparing for CJR-X: What Hospitals and Post-Acute Partners Should Do Now
ATI’s analysis of hospitals operating under similar episode-based models supports starting by characterizing historical LEJR volume, performance, and utilization patterns against regional benchmarks before performance year spending is at risk. Under CJR-X, hospitals could build performance-based PAC partnerships, extend care management further into the 90-day post-discharge period, and approach hospital discharge as the beginning of a longer care management arc.
For hospital and post-acute providers working through what CJR-X means for their market, ATI Advisory leaders have extensive experience operating bundled payments programs for hospitals, physician groups and post-acute care organizations.