CMS’ proposed Comprehensive Care for Joint Replacement Expanded (CJR-X) Model is expected to begin on October 1, 2027 and will require more than 2,500 hospitals to manage 90-day Medicare lower extremity joint replacement (LEJR) episodes spanning inpatient, outpatient, and post-acute care. The model uses regional, risk-adjusted target prices and ties financial performance to quality outcomes, with reconciliation payments based on total episode spending relative to benchmarks.
CJR-X will require two-sided financial risk from all participating hospitals from the model’s inception. Early preparation is crucial so that hospitals are equipped to succeed as soon as the model begins. Hospitals can start now by developing effective data-driven strategies to support performance throughout the model’s duration, which currently does not have an end date.
Success in CJR-X will require a comprehensive, claims-driven approach to understanding total cost of care across the full 90-day Medicare episode for LEJR procedures. As with similar models in recent years, successful organizations will be those that structure claims analysis to not only explain financial performance but also uncover actionable opportunities for clinical and operational improvement.
Through our experience supporting more than 400 hospitals in Medicare bundled payment programs, the following best practices have emerged.
Use Complete Medicare Claims Data
In a 90-day LEJR episode, 45% to 55% of spending occurs within the hospital and is relatively fixed. However, the rest is influenced by care delivered outside the hospital’s direct control. To fully understand financial outcomes, analysis must include hospital-based care and services across all providers and post-acute settings, as well as all readmissions—not just those that return to the original hospital. This level of granularity and insight requires access to both the Part A claims file and the Part B 100% claims file to provide a full picture of the hospital’s performance during a 90-day episode of care. Hospitals that use only internal data or a limited Medicare claims data set run the risk of basing care redesign decisions on an incomplete and inaccurate analysis.
Link Financial Outcomes to Clinical Decisions
To drive improvement, organizations must link financial variation back to clinical decision making. While claims data can identify where variation exists, it does not fully capture the underlying causes. High-performing hospitals in prior Medicare bundled payment programs have used claims analysis as a starting point to guide deeper investigation, enabling clinicians to identify opportunities to improve cost and quality outcomes.
As an example, post-acute care (PAC) is often one of the most significant drivers of variation in 90-day episodes, making it a key focus area for claims analysis. Too often, referral patterns reflect habit or throughput priorities instead of thoughtful decisions about the most appropriate post-acute setting and provider for each patient. In addition, many PAC providers lack visibility into how they influence financial outcomes within a 90-day LEJR episode. Transparency is, therefore, a powerful tool. By sharing claims-based performance data with surgeons, clinicians, discharge planners, and PAC provider partners, hospitals can highlight variation in cost and quality, identify improvement opportunities, and collaborate to drive change.
Include Patient-Level Analysis
CMS assigns each patient an individualized target price based on acuity and expected resource utilization, so patient-level analysis is essential. For example, fracture versus elective cases have fundamentally different clinical pathways, patient acuity levels, and expected costs. The stratification of claims data analysis should extend beyond procedure type to include patient risk, surgeon, and post-acute pathway. Evaluating performance at an aggregate level without accounting for these differences can mask important variation and produce misleading comparisons, e.g., a PAC provider treating higher-acuity patients may appear inefficient unless results are risk-adjusted appropriately.
Organizations should analyze the full cost distribution of cases and identify outliers for deeper review. Understanding what happened in these cases, including whether complications, poor care transitions, inadequate patient support, or some other controllable factor drove suboptimal outcomes, can reveal improvement opportunities and lead to intervention strategies based on real drivers of variation.
Supplement Claims Data With Additional Insights
Analysis of claims data is necessary to identify potential opportunities to standardize and improve care delivery pathways. However, claims data alone does not capture key elements such as functional status, social determinants, or patient support systems. These factors can significantly influence outcomes, particularly post-discharge. Combining claims data with electronic medical record data and insights from the care team and PAC providers can help organizations build a more complete understanding of care pathways and identify gaps that would otherwise remain hidden.
For example, a pattern of readmissions identified in claims data may prompt further analysis that reveals inadequate caregiver support at home or gaps in discharge education. This integration allows organizations to design more effective interventions tailored to patient needs.
Understand Regional CJR-X Episode Performance
Benchmarking is another essential component of effective claims analysis of LEJR episode performance. Because CJR-X target prices are based on regional data, hospitals must understand not only their own data but also how they compare to other hospitals in the region. Analyzing regional utilization patterns and performance trends for LEJR episodes provides critical context for broader market dynamics that will significantly impact final target prices in CJR-X. Benchmarking also helps address common clinician concerns, such as perceptions that a given surgeon’s patients are inherently more complex, by demonstrating how patients with a similar risk profile are managed across the region.
Establish Roles & Responsibilities for Implementing Data-Driven Changes
Governance and accountability structures play a vital role in translating data into results. Successful programs typically establish a multidisciplinary steering committee that includes finance, clinical, and operational leadership. This group meets regularly (often monthly) to review performance data, track progress, and prioritize interventions.
A dedicated program lead, often with a finance background, supports the steering committee. This individual is responsible for understanding the technical nuances of the episodic payment model, managing the analysis, and clearly communicating insights. They work closely with clinical champions, particularly orthopedic surgeons, to align stakeholders and drive change across the care continuum.
Tailor Data Insights & Communications to the Appropriate Audience
Effective communication of claims analysis findings is essential to driving adoption and action. For many stakeholders, presenting high-level financial outcomes is insufficient. For example, clinicians often require detailed, credible data to engage with findings. Providing visibility down to the individual claim level helps establish trust and demonstrates that the analysis is grounded in real, verifiable information. Regular reporting, typically on a monthly cadence for the steering committee, helps keep stakeholders engaged and focused on continuous improvement. Over time, this structured approach to communication fosters a culture of transparency and accountability.
How Forvis Mazars Can Help You Prepare for the CJR-X Model
Our value-based care team has developed time-tested data tools and capabilities through years of experience helping hospitals succeed in bundled payment models. We can help you implement data-driven best practices with an approach tailored to your organization. If you have questions about CJR-X or would like assistance preparing for the model, please reach out to our team today.