On July 31, 2026, the Centers for Medicare & Medicaid Services (CMS) finalized CJR-X (Comprehensive Care for Joint Replacement Expanded), changing how most U.S. hospitals are paid for joint replacement. Beginning January 1, 2028, most acute care hospitals nationwide must participate in the CJR-X Model, which holds them accountable for the cost and quality of hip, knee, and ankle replacement care — from the procedure through 90 days after discharge.
This is no longer a proposal or a pilot in a few cities. It is a mandatory, nationwide model affecting more than 2,500 hospitals — and it accelerates the shift toward coordinated, patient-centered care across the full surgical episode.
For the organizations that prepare early, CJR-X is as much an opportunity as an obligation.
What is CJR-X?
CJR-X expands the original Comprehensive Care for Joint Replacement Model, which ran in selected metropolitan areas from 2016 through 2024. CMS reports that the model saved an estimated $112.7 million in net Medicare spending in its final years (2021–2023) while maintaining quality across more than 98,000 hip and knee replacement patients at 323 hospitals. CJR-X takes that approach nationwide, with CMS projecting roughly $725 million in net savings over its first five performance years. It has no announced end date — that projection covers only the opening five years of an ongoing nationwide model, not a time-limited pilot.
Participation is required for most acute care hospitals paid under both Medicare's Inpatient and Outpatient Prospective Payment Systems (IPPS and OPPS). Hospitals in TEAM, hospitals in Maryland, and those not paid under both systems are excluded. The model covers Original Medicare patients undergoing lower-extremity joint replacement in an inpatient or hospital outpatient setting:
- Total hip replacement
- Total knee replacement
- Total ankle replacement (inpatient)
- Certain hip replacements performed for fracture
Ambulatory surgery centers are not direct participants, though patients still move between hospital and outpatient settings during the episode.
How will the payment model work?
Hospitals continue billing Medicare under existing fee-for-service systems. After each performance year, CMS compares each hospital's total episode spending — the procedure plus most related Part A and Part B services over the 90 days after discharge, including physician follow-up, rehabilitation, home health, skilled nursing, and readmissions — against a predetermined target price.
Hospitals that keep quality high and spending below target may earn a reconciliation payment; those above target may owe CMS a portion of the difference.
Quality comes first
CJR-X is not simply a cost-reduction program. CMS built it around a “quality first” principle: a hospital must meet a minimum composite quality score before it can receive any reconciliation payment, no matter how much it saved.
That composite score reflects performance and improvement across five measures:
- Complications following elective primary hip or knee replacement
- Hospital visits within seven days of hospital outpatient surgery
- Patient experience during a hospital stay (HCAHPS)
- Patient experience for outpatient and ambulatory surgery (OAS CAHPS)
- Patient-reported outcomes following hip or knee replacement
These measures broaden what counts as a successful joint replacement. Avoiding complications and controlling spending still matter — but so do patients' experiences and their self-reported recovery. Three of the five measures directly reflect the patient's experience or reported outcomes.
How is CJR-X different from TEAM?
CJR-X should not be confused with the Transforming Episode Accountability Model (TEAM), a separate model that began in January 2026. TEAM spans five surgical categories over a 30-day episode; CJR-X covers only lower-extremity joint replacement, runs a 90-day episode, and applies nationwide. Hospitals in TEAM are excluded from CJR-X until TEAM ends in 2030, then transition in.
Why patient preparation matters
CJR-X does not require a digital patient-education platform, but it raises the stakes for consistently preparing patients. A successful episode depends on far more than the operation: patients need to know how to prepare, what to expect in recovery, how to use medications safely, when to begin rehabilitation, and — critically — which symptoms are normal and which ones warrant a call or visit.
That last distinction carries real financial weight. A patient who doesn't know what's normal, or has no clear number to call, often defaults to the emergency department; one who's been taught what to expect calls the office instead, reaching a nurse who can reassure or redirect them. Under CJR-X, an avoidable ED visit is exactly the spending that counts against the episode — so turning an ED trip into a phone call is a direct, repeatable win.
More broadly, inconsistent or hard-to-access education leaves patients struggling to follow their recovery plan, driving delayed discharge, avoidable ED visits, and preventable readmissions that raise episode spending and can affect quality. The reverse is also true: patients who feel informed and supported tend to move through recovery more confidently and to rate their care experience more highly. Education alone won't determine an episode's outcome, but it is a core part of a coordinated system that helps patients recover safely and can support the patient-experience and recovery goals reflected in CJR-X's measures.
When patients know what's normal and who to call, a worried ED trip becomes a phone call — and a better experience.
Preparing for 2028
CJR-X does not begin until 2028, but the time to evaluate your joint replacement pathway is now — the hospitals best positioned on day one will be the ones that started early. Questions worth asking:
- Is patient education consistent across our surgeons and facilities?
- Can patients access it both before and after surgery?
- Is the education tailored to your facility and surgeon protocols?
- Can you track which patients received and completed it?
- Are education, care coordination, and patient-reported-outcome workflows connected?
- Where are patients experiencing confusion or preventable gaps in care?
The goal is not to bolt another disconnected tool onto an already complex pathway. It is to build a coordinated experience that gives patients the right information at the right time — and gives care teams real visibility into engagement.
Where OrthoSkool fits
OrthoSkool was built for this moment: surgeon-developed, procedure-specific education configured around your organization’s protocols. By preparing patients consistently for surgery and recovery, OrthoSkool can support fewer avoidable ED visits, better outcomes, and a more informed, coordinated patient experience.
CJR-X ties payment to patient experience and patient-reported outcomes, making patient preparation increasingly important. Three of the model’s five quality measures reflect the patient’s voice: HCAHPS, OAS CAHPS, and the hip and knee replacement patient-reported outcome measure. Although CMS does not identify education as a direct input to these measures, well-prepared patients may be better positioned to engage in recovery, follow their care plan, and navigate the surgical experience with greater confidence and satisfaction.
OrthoSkool is designed to help joint replacement programs:
- Standardize patient preparation across every surgeon and site
- Teach patients what's normal — and who to call when it isn't — so a worried patient phones your team instead of going to the ED
- Reduce the education burden on nurses and care coordinators
- Prepare patients for the full 90-day recovery
- Document patient participation and course completion for internal quality improvement
- Deliver a more informed, coordinated, and reassuring surgical experience
We won't claim education alone wins under CJR-X. But it is one of the highest-leverage, lowest-risk investments a joint replacement program can make before 2028.
