Perspective from Amy Finkelstein, PhD
October 05, 2018
4 min read

CMS report showed CJR model may reduce care episode costs

Under the CJR model, quality of care was also maintained despite concerns related to access to care

Perspective from Amy Finkelstein, PhD
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Bundled payments for lower-extremity joint replacement episodes may result in reduced payments under the Comprehensive Care for Joint Replacement model, according to the first annual report published by the CMS.

The report included findings from April 1, 2016, to December 31, 2016, reported by hospitals paid under the Medicare inpatient prospective payment system and located in the 67 metropolitan statistical areas included under the Comprehensive Care for Joint Replacement (CJR) payment model.

Reduced costs in episodes of care

In results in the report, there was a 3.3% decrease in total episode payments for CJR episodes compared with control group episodes. Metropolitan statistical areas with historically high and low episode payments experienced decreases in average total payments for CJR episodes of $1,127 and $577, respectively.

Separate analyses that were performed using data for elective lower extremity joint replacement and lower extremity joint replacement due to fracture showed a reduction in average total payments for both episodes, according to the CMS report.

The report noted there was a relative decrease in inpatient rehabilitation facility (IRF) as the first post-acute care setting used following elective episodes, as well as a relative increase in the home health agency as the first post-acute care setting used. Fracture episodes showed a relative increase in the proportion of patients discharged to a skilled nursing facility (SNF) and a decrease in the proportion of patients discharged to an IRF. Furthermore, there was a statistically significant relative reduction in the average number of days spent in the institutional post-acute care setting for CJR patients with elective or fracture episodes who were discharged to either a SNF or IRF.

“The report found that reductions in total episode payments were driven by reductions in the use of more intensive post-acute care settings and shorter lengths of stay in post-acute care settings, without indications of reduced quality of care,” a CMS spokesperson told Orthopedics Today.

Maintenance of quality care

The CMS spokesperson said quality of care was maintained under the CJR model with no impact on readmission rates, ED visits and mortality. Although incentives to admit healthier patients or avoid higher risk patients to reduce average total episode payments have raised concerns among participating hospitals regarding to how access to care for sicker or more resource intensive patients would be impacted, the CMS report showed “no indications that the CJR patient population was healthier in the intervention period than in the baseline, relative to the control group population.”


Ultimately, the report highlighted some common themes identified by participant hospitals that can be used as strategies in reducing episode costs.

“While the response to the CJR model varied across hospitals, hospitals reported that common themes in the strategies they took to reduce episode costs included bolstering patient education, optimizing high-risk patients prior to surgery, engaging surgeons in care redesign efforts, standardizing care pathways and protocols, following-up with patients after discharge and improving coordination with post-acute care providers,” the CMS spokesperson said. – by Casey Tingle


CMS Comprehensive Care for Joint Replacement model: Performance year 1 evaluation report. Available at: Accessed Sept. 18, 2018.

For more information:

CMS can be reached at 7500 Security Boulevard, Baltimore, MD 21244; email: