CMS has announced the nationwide expansion of its Comprehensive Care for Joint Replacement model — now called CJR-X — set to launch January 1, 2028. The program is the first mandatory, nationwide test of an episode-based payment model and will hold hospitals accountable for all Medicare spending tied to hip, knee, and ankle replacement surgeries, from hospitalization through 90 days post-discharge, including physical therapy and follow-up care.

Most hospitals under the Inpatient Prospective Payment System will be required to participate, with exceptions for those in Maryland, those already in the Transforming Episode Accountability Model, and facilities not covered under both inpatient and outpatient payment systems. CMS Administrator Mehmet Oz, MD, framed the expansion as a way to align financial incentives with better outcomes for seniors.

Not everyone is on board, though. Orthopedic surgeon Dr. P. Maxwell Courtney warns that many hospitals aren't ready for a mandatory program with 20% financial risk by 2028 — and raises concerns about excluding ambulatory surgery centers, limiting bundle management to hospitals only, and the potential for disproportionate financial strain on safety-net and tertiary centers.

Key Takeaways:

• CJR-X covers the full episode of care: surgery + 90 days of recovery
• Hospitals — not surgeons or ASCs — are the accountable entities, with no requirement to share savings with physicians
• Safety-net hospitals and tertiary centers may face disproportionate financial risk due to limited risk-adjustment measures

Why it matters: Mandatory bundled payment models reshape how hospitals and surgeons approach joint replacement care. If CJR-X rolls out as planned, it will affect a large share of Medicare joint replacement surgeries nationwide — making it one of the most significant orthopedic payment policy shifts in years.