The Comprehensive Care for Joint Replacement Expanded (CJR-X) Model is a mandatory bundled payment model that includes 90-day Medicare lower extremity joint replacement (LEJR) episodes spanning inpatient, outpatient, and post-acute care. As finalized in CMS’ fiscal year 2027 Inpatient Prospective Payment System (IPPS) final rule, the model’s start date is January 1, 2028, with more than 2,500 hospitals required to participate.
In CJR-X, CMS will hold hospitals financially accountable for both total episode spending relative to regional, risk-adjusted target prices and quality outcomes relative to national performance benchmarks. Hospitals will face two-sided risk beginning immediately upon the model’s start date, so early preparation is essential to success. While many organizations are rightly focused on understanding variation in LEJR episode costs, they need to apply equal focus to improving the quality measures included in the model.
This article explores how quality affects performance in CJR-X, as well as strategies and best practices hospitals can implement to support quality improvement leading up to and throughout the duration of the model.
How Does Quality Affect Performance & Payment in CJR-X?
CJR-X will include five quality measures, which will be combined into a composite quality score (CQS) that affects a hospital’s eligibility for reconciliation payment and the amount of that payment. The quality measures are:
- Hospital-Level Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) &/or Total Knee Arthroplasty (TKA)
- Hospital Visits Within 7 Days of Hospital Outpatient Department (HOPD) Surgery
- Hospital Consumer Assessment of Healthcare Providers & Systems (HCAHPS) Survey
- Outpatient & Ambulatory Surgery Consumer Assessment of Healthcare Providers & Systems Survey (OAS CAHPS)
- Hospital-Level THA &/or TKA Patient-Reported Outcome-Based Performance Measure (PRO-PM)
CMS will score quality measures relative to national performance benchmarks. This means that to succeed in CJR-X, a hospital will not only need to improve quality scores relative to its own historic performance, but it will also need to improve at a faster rate than the overall improvement in national performance.
Hospitals with favorable episode spending relative to their target price will be required to meet a minimum CQS threshold to receive a reconciliation payment. A higher CQS will result in larger positive reconciliation payments, while poor quality performance will reduce reconciliation payments or disqualify hospitals from receiving any positive reconciliation payment.
The role of quality in CJR-X is a significant departure from prior voluntary bundled payment models, such as Bundled Payments for Care Improvement Advanced (BPCI-A), in which many participants achieved savings without substantially emphasizing quality improvement. In CJR-X, quality is a stage gate to financial success. Hospitals that focus exclusively on cost reduction risk ineligibility for reconciliation payments if their quality performance lags the national minimum CQS threshold. In the original CJR Model, 8% to 12% of hospitals were deemed ineligible to earn financial gains from CJR due to poor quality.
Conversely, if a hospital’s quality performance and CQS are superior, its target price for patient services will increase, effectively increasing the allowed budget for its patients and making financial success in the model more attainable. Organizations that integrate quality improvement into their CJR-X strategy may be better positioned to increase savings, which can create a larger gainsharing pool for physicians for hospitals that choose to pursue this approach.
Breaking Down CJR-X Quality & Cost Scenarios
CQS results are both a prerequisite for eligibility for model-based financial gain (referred to as the net payment reconciliation amount, or NPRA) and a determinant of target prices—a better CQS is rewarded with higher, more advantageous target prices, which in turn means a higher potential NPRA. These two factors are important, as is episodic efficiency to reduce Medicare expenditure. Focusing exclusively on one or the other is a short-sighted strategy with potentially negative consequences.
To illustrate the potential consequences, below are two plausible scenarios in which hospitals focus on either CQS or NPRA at the expense of the other.
Scenario 1: “Excellent” CQS, Poor Cost Performance
In this scenario, the hospital achieves an “Excellent” CQS but overspends on the advantageous target price. Note that because of the CQS and the corresponding rating, CMS takes a 0% discount and does not reduce the target price. However, even an “Excellent” CQS still results in a net-negative NPRA and a repayment to CMS.
| Metric | Per Case | Rating/Adjustment |
|---|---|---|
| Base Target | $20,000 | |
| CQS Score, Rating | 18.0/20, “Excellent” | |
| CMS Discount | - | 0% |
| Adjusted Target | $20,000 | |
| Cost of Claims | $21,000 | |
| NPRA | ($1,000) |
Scenario 2: “Below Acceptable” CQS, Successful Cost Performance
In the opposite scenario, the hospital focuses only on cost at the expense of quality. As a result, the example hospital achieves a “Below Acceptable” CQS, making it ineligible to receive the NPRA and effectively nullifying its would-be gains.
| Metric | Per Case | Rating/Adjustment |
|---|---|---|
| Base Target | $20,000 | |
| CQS Score, Rating | 5.0/20, “Below Acceptable” | |
| CMS Discount | $400 | 2% |
| Adjusted Target | $19,600 | |
| Cost of Claims | $19,000 | |
| NPRA | Ineligible |
How Can Hospitals Align Quality Reporting & CJR-X Teams?
To reduce administrative burden, CMS will use measures from the Medicare Inpatient Quality Reporting (IQR) Program and Medicare Outpatient Quality Reporting (OQR) Program. One challenge a participating hospital may face is the disconnect between the team responsible for the IQR and OQR measures and the CJR-X team.
Importantly, three of the five CJR-X quality measures are hospital-level measures that extend beyond LEJR patients and episodes. As a result, focusing on quality improvement efforts solely within the orthopedic service line is unlikely to maximize CJR-X quality performance. Hospitals should engage quality leaders and service lines across the organization, including areas outside orthopedics, to identify and close performance gaps that influence the overall CJR-X quality score.
How Does Standardizing Clinical Pathways Support Quality Improvement?
Hospitals preparing for CJR-X should focus on reducing unnecessary variation in care delivery between surgeons, sites of service (inpatient versus outpatient), or patients. The goal is to create a consistent experience that reduces complications, improves patient outcomes, and supports high-quality care throughout the episode, from preoperative preparation through post-discharge recovery.
Key areas on which to focus when standardizing pathways include:
- Infection Control: Infection prevention remains critical, including appropriate use of prophylactic antibiotics and adherence to surgical protocols.
- Adverse Events: Preventing adverse events, such as blood clots, complications related to pain management (particularly reducing reliance on opioid medications as appropriate), and medication events, through pre-discharge reconciliation helps reduce complication rates and improve recovery.
- Prehabilitation: For elective procedures, using pre-surgical physical preparation (commonly known as “prehabilitation”) can help reduce readmission risk for patients who are diabetic by better controlling A1C and bringing down body mass index (BMI) for overweight patients. If a patient’s lower body and core are weak, building strength before the procedure is crucial to starting rehabilitation immediately post-surgery. In addition to helping improve quality measures, reduce readmissions, and improve PROs, prehabilitation supports discharging the patient to the most appropriate site post-procedure.
What Role Does Patient Navigation Play in Quality Improvement?
Patient navigation is one of the most effective interventions available to help hospitals manage quality outcomes. Navigators help patients understand care plans, coordinate appointments, address concerns, and connect with the appropriate provider before problems escalate. This relationship becomes particularly valuable during the post-discharge period, when uncertainty or unanswered questions can lead patients to seek emergency department care unnecessarily.
Navigators can also provide operational advantages. Because they maintain regular contact with patients, they can identify developing trends across patients, such as rising infection rates, missed therapy appointments, medication issues, or shifts in discharge patterns. These near-real-time insights allow hospitals to intervene before problems negatively affect reported quality measures. Given the significant lag associated with many CMS quality metrics, these operational signals can be far more actionable than waiting for issues to emerge in claims data or CJR-X performance results.
How Can Hospitals Engage Physicians in Quality Improvement?
Physician engagement is necessary for improving quality. Surgeons influence nearly every aspect of a CJR-X episode, including site-of-procedure selection, patient uptake of prehabilitation, discharge planning, and follow-up care. Their practice patterns can substantially impact quality outcomes and episode costs.
CJR-X hospitals should begin engaging surgeons well before CJR-X takes effect by providing detailed, physician-specific performance data. Physician scorecards showing readmission rates and other risk-adjusted quality metrics can help clinicians understand their performance and identify opportunities for improvement. When surgeons can review objective data and compare their results against blinded or identified peers, they are often more willing to participate in care standardization efforts and pathway redesign.
Hospitals can further incentivize physician engagement through gainsharing arrangements. However, their effectiveness depends on aligning incentives with measures physicians can directly affect and that are likely to improve performance on the quality metrics included in the CQS.
How Can CJR-X Hospitals Improve Patient-Reported Outcomes (PROs)?
For many hospitals, response rates on the PRO measures will present a challenge. Hospitals had the opportunity to voluntarily report THA/TKA PRO-PM data through June 30, 2024, and mandatory reporting requirements took effect on July 1, 2024 under the fiscal year 2027 Hospital IQR Program. Therefore, many organizations struggle with who is responsible for the workflow design and patient outreach necessary to increase responses. Manual processes frequently result in missed surveys and inconsistent response rates.
To help drive accountability and hardwire the necessary process changes, hospitals should view PRO collection as a performance improvement tool rather than simply a compliance requirement. Organizations that successfully use PROs often have navigators or vendors who help collect feedback, share results with surgeons, and convert patient insights into actionable improvements in clinical pathways and operational processes.
When Should Hospitals Start Preparing for CJR-X Quality Improvement?
The most important lesson from previous bundled payment models is that quality improvement takes time. Quality measures are lagging indicators based on prior performance periods, and meaningful improvement may require several years of sustained effort. Hospitals already know whether they have been selected for CJR-X participation, so now is the ideal time to analyze claims data, identify drivers of readmissions and complications, and implement standardized care pathways. Organizations that wait until the model begins will likely find themselves behind peers that started preparing earlier.
One common barrier is the misconception that since official IQR and OQR results and comparative data are generated annually, quality results may only be meaningfully assessed annually. Hospitals should be aware that information worth studying, and from which they may identify trends, is available constantly.
Ultimately, high-performing CJR-X organizations will likely be those that view quality not just as an annual reporting requirement, but as the foundation of their bundled payment strategy. Standardizing care pathways, strengthening care coordination, engaging physicians, leveraging patient navigators, and acting on quality data can help hospitals improve both patient outcomes and financial opportunities under the new model.
How Forvis Mazars Can Help You Prepare for the CJR-X Model
Our value-based care team has extensive experience supporting hospital performance in alternative payment models, including TEAM, ASM, CJR, BPCI-A, and more. We have the tools and capabilities to help you understand your organization’s current performance in the CJR-X quality measures and identify and execute on improvement opportunities before the model begins. If you have any questions about CJR-X or would like assistance with quality improvement, please reach out to our team today.