CJR-X Is the Future of Value-Based Care

When the Comprehensive Care for Joint Replacement Expanded Model (CJR-X), a mandatory bundled payment model for lower extremity joint replacement, takes effect January 1, 2028, more than 2,500 eligible acute care hospitals nationwide will be required to participate. The Centers for Medicare and Medicaid Services (CMS) estimates the model will generate $725 million in Medicare savings during its first five performance years. And, unlike many payment models that preceded it, CJR-X has no specified end date. 

The immediate impact of the expanded pilot program for lower extremity joint replacements will be significant. Its longer-term significance lies in what CJR-X signals: an ongoing shift from paying for individual services to holding hospitals accountable for the cost, quality and outcomes of care across an episode. The program also follows a broader movement by the CMS Innovation Center toward mandatory participation and financial risk in value-based payment models. 

This makes CJR-X more than another CMS mandate for hospitals to prepare for. It’s another indication that the capabilities needed to succeed in value-based care — understanding performance, reducing unnecessary variation, coordinating care across settings and improving outcomes — have greater effects to how healthcare organizations will be paid.

CJR-X is expanding the definition of performance.

Rather than focusing primarily on the joint replacement procedure itself, CJR-X will hold healthcare organizations accountable for the cost and quality of care across a 90-day episode that includes most related Medicare Part A and Part B services, from the procedure and hospital stay to rehabilitation, follow-up care and other services delivered after discharge. 

Performance decisions made throughout the episode — care pathways, discharge destinations, rehabilitation utilization and follow-up care — can influence patient outcomes as well as the total cost of care. Hospitals may not directly provide every service within that continuum. Under CJR-X, however, a health system’s financial performance will be tied to how effectively those services work together.

Success, therefore, will require organizations to look beyond traditional clinical and operational boundaries. That means engaging physicians around evidence-based care pathways, identifying and reducing unnecessary variation, strengthening relationships with post-acute providers and coordinating transitions so patients receive the right care in the right setting.

The first step to CJR-X isn’t changing care. It’s understanding performance.

Before a hospital starts redesigning pathways or asking clinicians to change their behavior, leaders need visibility into how they have performed historically:

• Where are we today?
• How would our historical episodes perform against CJR-X target prices?
• Where does variation exist?
• What’s driving episode cost? 
• Where is our greatest financial opportunity or exposure?
• Which changes would produce the greatest impact?

The answers to these questions can reveal opportunities that are difficult to see when clinical, financial and utilization data are viewed separately. 

For example, a hospital may find that greater use of inpatient rehabilitation, rather than home health for clinically appropriate patients, is affecting costs. Identifying that variation in costs by examining care pathways creates a specific opportunity to potentially reduce costs and transform financial loss into savings, rather than just issuing broad directives to reduce costs.

Premier’s approach begins by bringing those pieces together through an Episode Opportunity Analysis, using historical performance to help hospitals understand how they would perform under CJR-X and identify and prioritize the clinical and financial opportunities. 

Data identifies the opportunity and change management captures it.

Knowing where variation exists doesn’t necessarily eliminate it. Analytics can identify what a hospital should change, but data alone can’t make that change happen. For health systems without significant bundled-payment or value-based experience, translating insight into action can require substantial change management — engaging surgeons, clinical leaders, care navigators and post-acute providers around common goals for quality, utilization and cost while rethinking established care pathways, discharge practices and post-acute relationships.

This is where experience and relationships become especially valuable. Premier’s Bundled Payment Collaborative goes beyond performance monitoring and dedicated one-on-one coaching by connecting hospitals with peers working through many of the same clinical and operational challenges. Members find out what worked, what didn’t and how successful approaches can be adapted to their own environment. And Premier’s historical experience provides proof: 

Premier members achieved 86 percent higher savings than the nation through performance year six under the original CJR program and earned $200 million in additional revenue under all CMS bundled payment models over the last 10 years.

CJR-X begins January 2028. Preparation should start much sooner.

The final rule established a January 1, 2028, start date, which is delayed from the October 2027 start date originally proposed. This gives hospitals additional time to prepare for CJR-X. But that time shouldn’t be reason to wait.

Health systems that use the remainder of 2026 to assess current performance can use 2027 as a year of action: prioritizing opportunities, implementing changes and monitoring their impact before financial accountability begins. Premier’s phased approach is designed around that progression, beginning with an Episode Opportunity Analysis to understand current performance and moving into implementation support as organizations prepare for model go-live.

The goal should not be to have a CJR-X strategy in place by January 2028; it should be to have that strategy already working before the model goes live. 

December 31, 2026: Understand
Analyze your current performance and identify opportunities.

Early 2027: Design
Prioritize interventions, engage physicians and redesign pathways.

Mid/Late 2027: Implement
Standardize care, strengthen post-acute coordination and monitor performance.

January 1, 2028: Perform
Risk begins Day 1. Enter CJR-X with infrastructure already operating rather than beginning the transformation.

Experience matters when accountability becomes mandatory.

CJR-X may be a new model, but the work required to succeed under it is not new to Premier. For more than a decade, Premier has worked with hospitals participating in bundled payment models, helping them understand performance, identify opportunities and translate insights into meaningful improvements in care.

That experience matters as episode-based accountability expands. Premier combines claims-based analytics with dedicated coaching, peer-to-peer learning and ongoing performance monitoring to help hospitals move from understanding where opportunities exist to building the clinical and operational capabilities needed to act on them.

January 1, 2028, is an important milestone, but CJR-X readiness is only part of it. Hospitals that take advantage of the time ahead to improve coordination across the continuum will be better positioned not only for CJR-X, but for a healthcare environment increasingly defined by accountability for cost, quality and outcomes.

That work can begin now, and hospitals don’t have to do it alone.

Start preparing for CJR-X with a better understanding of where your organization stands today. Premier can help you benchmark current episode performance, identify opportunities to reduce variation and build a roadmap for success before the model takes effect.