Comprehensive Care for Joint Replacement, universally called CJR, is the CMS Innovation Center's flagship mandatory bundled payment model and the longest-running mandatory CMMI bundle in Medicare history. CJR launched in 2016 in selected Metropolitan Statistical Areas (MSAs), and the Atlanta-Sandy Springs-Roswell MSA was included from the start. For Atlanta-area hospitals exceeding the volume thresholds, including Wellstar Kennestone, Piedmont Atlanta, Piedmont Henry, Northside Atlanta, Emory University Hospital Midtown, Grady Memorial, and others, CJR fundamentally restructured how hip and knee replacement programs are operated. The model holds each participating hospital accountable for a 90-day episode beginning with the anchor admission and ending 90 days post-discharge, against a hospital-specific Target Price blended with a regional benchmark.

This guide explains how CJR works, who participates, how Target Prices and reconciliation operate, what CJR means for Atlanta-area beneficiaries and hospitals, and how CJR relates to BPCI Advanced and the upcoming TEAM mandatory model.

By Brevy Care Team

The statutory and regulatory foundation

CJR rests on a clear regulatory architecture distinct from most other CMMI models, implemented through formal rulemaking and codified in regulation:

  • Section 1115A of the Social Security Act: the CMS Innovation Center statutory framework, added by the Affordable Care Act. CJR is a Section 1115A demonstration.
  • CJR Final Rule: established the mandatory model design, participant selection methodology, episode definitions, Target Price methodology, reconciliation rules, and quality measures.
  • 42 CFR Part 510: the implementing regulations for CJR. Part 510 codifies the participation requirements, episode definitions, payment methodology, quality measurement, and beneficiary protections.
  • Cost-Containment Rule: reduced the number of mandatory MSAs and made participation voluntary in others (Atlanta MSA remained mandatory).
  • CY 2021 Final Rule: extended CJR beyond its original performance period.
  • CY 2023 Extension Rule: provided a final extension through December 31, 2025.
  • TEAM Final Rule: established CJR's mandatory successor, effective January 1, 2026.

CJR's foundation in formal rulemaking, unlike most CMMI demonstrations that operate through Participation Agreements alone, reflects its mandatory nature. Forcing hospitals to participate in a model requires the procedural protections of notice-and-comment rulemaking.

The CJR performance period

CJR has operated across multiple Performance Years through 2024 and is in its final extension year ending December 31, 2025:

  • Performance Year 1: 2016 (transition launch year)
  • Performance Year 2: 2017
  • Performance Year 3: 2018
  • Performance Year 4: 2019
  • Performance Year 5: 2020 (original sunset year)
  • Performance Year 6 (extension): January–September 2021
  • Performance Year 7 (extension): October 2021–2022
  • Performance Year 8 (CY 2023): 2023
  • Performance Year 9 (CY 2024): 2024
  • Performance Year 10 (CY 2025, final): 2025

CJR sunsets December 31, 2025; TEAM takes effect January 1, 2026 in selected MSAs.

The CJR clinical scope

CJR's clinical scope is narrower than BPCI Advanced, focused exclusively on lower extremity joint replacement (LEJR):

Anchor inpatient stays

  • MS-DRG 469: Major Joint Replacement or Reattachment of Lower Extremity With Major Complication or Comorbidity (MCC)
  • MS-DRG 470: Major Joint Replacement or Reattachment of Lower Extremity Without MCC

Outpatient hip and knee replacement

  • Added in later performance years as elective hip and knee replacement shifted to outpatient settings
  • Equivalent procedures performed in hospital outpatient departments

Procedures covered

  • Total Hip Arthroplasty (THA)
  • Total Knee Arthroplasty (TKA)
  • Partial Hip/Knee Replacement
  • Bilateral procedures
  • Revision procedures (selected)
  • Hip fracture procedures (selected, though hip fracture has separate higher MS-DRG mapping in some cases)

CJR's narrow scope, essentially the most-volume bundle in BPCI/BPCI Advanced, makes it operationally focused on a single clinical service line. This is fundamentally different from BPCI Advanced's broad clinical category coverage.

The 90-day episode structure

CJR uses a 90-day episode structure:

Episode start

  • Anchor inpatient admission (MS-DRG 469/470) OR
  • Anchor outpatient hip/knee replacement procedure

Episode end

  • 90 days post-discharge or post-procedure

What's included in the episode

  • Anchor hospitalization
  • Surgeon, anesthesia, and hospital-based physician services
  • Post-acute care:
    • Skilled Nursing Facility (SNF) stays
    • Inpatient Rehabilitation Facility (IRF) stays
    • Long-Term Care Hospital (LTCH) stays
    • Home Health agency visits
  • Outpatient physical therapy
  • Outpatient physician visits (orthopedic and primary care)
  • Any readmissions
  • DME (durable medical equipment)
  • Part B drugs
  • Hospice (rare for elective hip/knee)

The 90-day window captures everything the patient experiences in the recovery period, and most of CJR's improvement opportunity lives in optimizing post-acute care.

The Target Price methodology

CJR's Target Price methodology differs from BPCI Advanced in one major way: regional benchmark blending.

Components

  1. Hospital-specific historical baseline: average episode spending at that hospital over a baseline period
  2. Regional benchmark: average episode spending across hospitals in the same regional grouping (typically the Census Division)
  3. Blend ratio: initially weighted toward hospital-specific; shifted toward regional over time
  4. Trend factor: annual update for cost trends
  5. Discount factor: varies by performance year

Why regional blending matters

The hospital-specific component rewards (or penalizes) hospitals based on their own baseline. The regional component rewards (or penalizes) hospitals against their regional peers. Over time, the blend shifted toward regional weighting, which:

  • Rewards hospitals that are below regional average (efficient hospitals do well)
  • Penalizes hospitals that are above regional average (inefficient hospitals struggle)
  • Encourages convergence toward best-practice spending levels

Comparison to BPCI Advanced

  • BPCI Advanced uses hospital-specific baseline only (no regional blend in most cases)
  • CJR's regional blend is more aggressive at driving efficiency convergence

Reconciliation methodology

CJR reconciliation occurs annually, comparing actual episode spending to Target Price:

Stop-loss / stop-gain limits

  • Initial performance years had relatively narrow stop-loss/stop-gain limits
  • Limits increased across performance years
  • More mature performance years have wider limits

Quality-weighted reconciliation

  • CJR uses a Composite Quality Score based on three quality measures
  • Quality score determines the percentage of earned savings hospital can retain
  • High-quality hospitals retain more savings; low-quality hospitals retain less or none

Net Payment Reconciliation Amount (NPRA)

  • If actual < Target Price: hospital receives reconciliation payment (capped at stop-gain)
  • If actual > Target Price: hospital owes reconciliation repayment (capped at stop-loss)

Repayment phase-in

  • Early performance years had no downside repayment (one-sided risk)
  • Later performance years introduced two-sided risk with phased stop-loss limits

The three quality measures

CJR measures performance on three quality measures:

1. Hip/Knee Complications Rate

  • Risk-Standardized Complication Rate following primary elective THA/TKA
  • 90-day complication rate
  • Includes mechanical complications, infection, readmissions for complication
  • Lower is better

2. HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems)

  • Hospital-level survey of patient experience
  • Already collected for IPPS hospitals
  • Reused as CJR quality measure

3. THA/TKA Patient-Reported Outcomes (PRO)

  • Voluntary submission of pre- and post-operative patient-reported outcomes
  • Hip Disability and Osteoarthritis Outcome Score (HOOS), Knee Injury and Osteoarthritis Outcome Score (KOOS), and similar
  • Submitted for credit in Composite Quality Score
  • Designed to elevate patient-reported recovery measurement

The Composite Quality Score combines these three measures, weighted appropriately. The Composite Score determines a hospital's quality category (Excellent, Good, Acceptable, Below Acceptable) which then determines:

  • Whether the hospital can earn savings (Acceptable or better required)
  • The fraction of savings retained
  • The hospital's exposure to losses

Advanced APM Status: Limited Pathway

CJR is generally not an Advanced APM under Section 1833(z) SSA. The standard CJR participation track does not satisfy the meaningful-risk threshold required for Advanced APM status. However:

  • A limited Advanced APM CJR track exists for hospitals that elect a higher-risk participation option and meet additional requirements
  • The standard CJR track is a MIPS APM, not an Advanced APM
  • Most Atlanta-area CJR participating hospitals are in the standard track

For physicians, CJR's Advanced APM status matters less because most participating hospital physicians achieve QP status through MSSP, ACO REACH, or other Advanced APMs rather than CJR.

Mandatory Atlanta MSA participation

The Atlanta-Sandy Springs-Roswell MSA was one of the originally-selected mandatory CJR MSAs. After the Cost-Containment Rule, the Atlanta MSA remained mandatory while many other MSAs converted to voluntary.

Participating Atlanta MSA hospitals (illustrative)

  • Wellstar Kennestone Hospital (Cobb County)
  • Wellstar Atlanta Medical Center (closed November 2022, was a CJR participant before closure)
  • Piedmont Atlanta Hospital
  • Piedmont Henry Hospital
  • Northside Hospital Atlanta
  • Emory University Hospital Midtown
  • Grady Memorial Hospital
  • Children's Healthcare of Atlanta (not a CJR participant, pediatric)
  • Other volume-threshold hospitals in the Atlanta MSA

Hospital participation is determined by volume thresholds and IPPS status. Smaller hospitals below volume thresholds may be excluded.

Atlanta MSA geographic boundaries

The Atlanta-Sandy Springs-Roswell MSA is defined by OMB and includes (as of 2023 MSA definition):

  • Barrow, Bartow, Butts, Carroll, Cherokee, Clayton, Cobb, Coweta, Dawson, DeKalb, Douglas, Fayette, Forsyth, Fulton, Gwinnett, Haralson, Heard, Henry, Jasper, Lamar, Meriwether, Morgan, Newton, Paulding, Pickens, Pike, Rockdale, Spalding, and Walton counties, plus a few additional surrounding counties

Hospitals located in any of these counties that meet CJR volume thresholds are subject to CJR.

Relationship to BPCI Advanced

BPCI Advanced cannot include MJRLE (Major Joint Replacement Lower Extremity) in CJR MSAs.

In the Atlanta MSA:

  • Hip/knee replacement falls under CJR (mandatory)
  • BPCI Advanced participants in Atlanta MSA cannot also include MJRLE under BPCI Advanced
  • Atlanta MSA hospitals can participate in BPCI Advanced for non-MJRLE bundles (cardiac, sepsis, stroke, COPD, etc.)
  • A single Atlanta hospital may be in CJR (for MJRLE) and BPCI Advanced (for non-MJRLE bundles) simultaneously

This precedence rule prevents double-bundling of the same clinical episode and preserves CJR's mandatory scope.

Relationship to QPP / MIPS

For physicians performing hip/knee replacement at CJR hospitals:

  • CJR by itself is not an Advanced APM
  • Standard CJR is a MIPS APM (limited)
  • Physicians who want QP status need participation in MSSP, ACO REACH, BPCI Advanced, or other Advanced APMs
  • Many Atlanta orthopedic surgeons participate in MSSP through their hospital affiliations

CJR's effects on physicians are indirect, through how the hospital operates the joint replacement program, not through direct physician-level payment changes.

TEAM: The Mandatory Successor (January 1, 2026)

The Transforming Episode Accountability Model (TEAM) is the mandatory successor to both CJR and BPCI Advanced, finalized in the CY 2025 IPPS Final Rule.

TEAM and Atlanta MSA

  • TEAM applies to hospitals in randomly selected MSAs
  • The CY 2025 IPPS Final Rule listed the selected MSAs
  • Atlanta MSA inclusion in TEAM is determined by the random selection methodology
  • Some Georgia hospitals will be subject to TEAM regardless of CJR participation

TEAM design vs. CJR

Feature CJR TEAM
Mandatory Yes (selected MSAs) Yes (selected MSAs)
Episode duration 90 days Shorter episode per final rule
Clinical scope LEJR only Multiple clinical categories
Target Price Hospital + regional blend Regional benchmark
Advanced APM Limited pathway Selected tracks

TEAM's shorter episode fundamentally changes which post-acute spending falls inside the bundle compared to CJR's 90-day design.

Atlanta MSA CJR: The Operational Story

CJR transformed how Atlanta MSA hospitals operate hip and knee replacement programs:

Pre-CJR (before 2016)

  • Standard fee-for-service: hospital paid per DRG, post-acute providers paid separately
  • Limited financial accountability for post-acute spending
  • High SNF utilization among joint replacement patients
  • Limited care coordination across the recovery window

Post-CJR (after 2016)

  • Substantial reductions in SNF utilization in many programs
  • Shorter average SNF length of stay
  • More home discharges with home health support
  • Enhanced rapid-recovery protocols
  • Pre-operative patient optimization (medical clearance, pre-habilitation)
  • Standardized clinical pathways
  • Improved transitions of care
  • Reduced 90-day readmissions

These operational changes have generated meaningful Medicare savings across CJR MSAs, and Atlanta MSA hospitals are among the participating regions that have contributed to those savings.

14 best practices for CJR-participating hospitals

  1. Pre-operative optimization: medical clearance, anemia treatment, smoking cessation, diabetes optimization
  2. Pre-habilitation: strength and conditioning before surgery improves recovery
  3. Patient selection: appropriate candidate identification reduces complications
  4. Standardized clinical pathways: same-day mobilization, multimodal pain management, rapid recovery protocols
  5. SNF utilization reduction: appropriate home discharge with home health support
  6. SNF network curation: preferred SNF partners with bundle-aligned protocols where SNF is appropriate
  7. Home health integration: strong home health partners with rapid response capability
  8. Outpatient PT optimization: coordinated outpatient PT regimen
  9. Care navigation: patient navigators managing the 90-day journey
  10. Pre-discharge planning: discharge planning starts pre-admission
  11. Surgical safety and infection prevention: SCIP measures and beyond
  12. Quality data submission: voluntary PRO submission strengthens Composite Quality Score
  13. Readmission prevention: 7-day follow-up appointment, medication reconciliation
  14. Vendor and implant cost management: implant standardization can yield meaningful savings

14 common CJR issues

  1. SNF length-of-stay drift: without active management SNF days exceed bundle targets
  2. Complications spike: risk-standardized complication rate is hard to drive down quickly
  3. HCAHPS score weakness: hospital-wide HCAHPS affects CJR Composite Quality Score
  4. PRO submission gaps: failing to submit voluntary PRO loses Composite Quality Score points
  5. Patient selection drift: accepting borderline candidates increases complication rates
  6. Pre-op optimization gaps: diabetic patients with high HbA1c have higher complication rates
  7. Home discharge anxiety: discharge planners may default to SNF unnecessarily
  8. Readmission for medical comorbidities: non-orthopedic readmissions still count
  9. Outlier episodes: single very high-cost episode can swing bundle reconciliation
  10. Implant cost overruns: surgeon preferences may drive implant cost variability
  11. Target Price recalibration: annual Target Price updates can shift unfavorably
  12. Regional blend disadvantage: hospitals in high-cost regions are disadvantaged by the blend
  13. TEAM transition planning: hospitals must plan for TEAM mandatory participation
  14. BPCI Advanced double-bundle prohibition: CJR hospitals cannot include MJRLE under BPCI Advanced

Six Worked Examples: Georgia Medicare Beneficiaries and CJR

1. Fulton 70: Atlanta MJR Hip Replacement CJR

A 70-year-old Fulton County beneficiary undergoes elective total hip arthroplasty at Emory University Hospital Midtown. Because Atlanta MSA is in CJR, the 90-day episode is governed by CJR (not BPCI Advanced, even if Emory participates in BPCI Advanced for other bundles). Emory's pre-operative optimization team prepares her for surgery; she discharges home with home health; outpatient PT follows; 90-day spending is reconciled against Emory's CJR Target Price.

2. DeKalb 75: DeKalb TKA CJR

A 75-year-old DeKalb beneficiary undergoes total knee arthroplasty at Northside Hospital Atlanta. CJR governs the 90-day episode. Standard rapid-recovery protocol: same-day mobilization, multimodal pain management, discharge to home with home health on Day 2-3, outpatient PT for weeks 2-12. Northside's CJR Composite Quality Score determines its share of any earned savings.

3. Cobb 68: Cobb THA at Wellstar Kennestone

A 68-year-old Cobb beneficiary undergoes elective total hip arthroplasty at Wellstar Kennestone (Cobb County, Atlanta MSA). CJR governs. Wellstar's pre-habilitation program prepares him for surgery, pre-op anemia management optimizes his blood counts, and a same-day mobilization protocol gets him on his feet within hours of surgery. He discharges home with home health on Day 2. 90-day spending is well below Wellstar's Target Price.

4. Worth County 72: Albany Hospital (Non-CJR MSA)

A 72-year-old Worth County beneficiary undergoes total knee arthroplasty at an Albany-area hospital. Albany is not in the Atlanta MSA and Albany hospitals are not in CJR. The episode follows standard Medicare FFS without CJR bundle accountability. The Albany hospital may participate in BPCI Advanced for MJRLE (which would govern the episode) if it elected to do so.

5. Bibb 80: Macon (Non-CJR MSA)

An 80-year-old Bibb beneficiary undergoes hip fracture repair at a Macon hospital. Macon is not in the Atlanta MSA and is not in CJR. The hospital follows standard Medicare FFS unless it elects BPCI Advanced for the hip fracture bundle.

6. Hall 67: Gainesville (Non-CJR MSA)

A 67-year-old Hall County beneficiary undergoes elective total knee arthroplasty at a Gainesville hospital. Gainesville is not in the Atlanta MSA and Gainesville hospitals are not in CJR. The episode follows standard Medicare FFS or BPCI Advanced if elected.

These examples illustrate CJR's geographic concentration: the same procedure performed in Atlanta MSA falls under mandatory CJR, while the same procedure 60-100 miles outside the MSA falls under standard FFS or voluntary BPCI Advanced.

Frequently Asked Questions

General CJR questions

CJR is the CMS Innovation Center's mandatory bundled payment model for lower extremity joint replacement, launched in 2016 in selected MSAs including the Atlanta MSA. CJR holds participating hospitals accountable for 90-day episodes for MS-DRG 469 and MS-DRG 470 plus outpatient hip/knee replacement equivalents.

2. What is the statutory basis? Section 1115A of the Social Security Act (the CMMI authority), implemented through the CJR Final Rule and codified at 42 CFR Part 510.

3. When does CJR operate? CJR launched in 2016 and runs through December 31, 2025. CJR has been extended multiple times.

Yes, the Atlanta-Sandy Springs-Roswell MSA was one of the originally-selected mandatory CJR MSAs and has remained mandatory throughout the model's operation.

Hospitals exceeding volume thresholds, including Wellstar Kennestone, Piedmont Atlanta, Piedmont Henry, Northside Atlanta, Emory University Hospital Midtown, Grady Memorial, and others.

Episode and payment questions

6. What does CJR cover? MS-DRG 469 (Major Joint Replacement With MCC), MS-DRG 470 (Without MCC), and outpatient hip and knee replacement procedures.

7. How long is the CJR episode? 90 days from the date of anchor admission or outpatient procedure.

8. What's in the 90-day episode? All Medicare Part A and Part B spending, including the anchor hospitalization, physician services, post-acute care (SNF, IRF, home health), outpatient PT, readmissions, DME, and Part B drugs.

9. How is the Target Price calculated? A blend of hospital-specific historical baseline and regional benchmark, trended forward and discounted. The blend has shifted toward regional weighting over performance years.

10. What is the Composite Quality Score? A score combining Hip/Knee Complications Rate, HCAHPS, and THA/TKA Patient-Reported Outcomes. Determines a hospital's quality category and its share of earned savings.

Beneficiary questions

Operationally, CJR is invisible to beneficiaries. They retain all Medicare FFS benefits and freedom of choice, can choose any post-acute provider, see any Medicare provider, and have no enrollment or cost changes.

12. Can beneficiaries opt out of CJR? No, but CJR has no operational effect on beneficiary choice. Hospital decisions about pathways may indirectly affect care, but beneficiaries retain full Medicare rights.

13. Does CJR affect beneficiary cost-sharing? No, standard Medicare Part A and Part B cost-sharing applies.

14. Can CJR hospitals restrict post-acute provider choice? No, beneficiaries retain freedom of choice. Hospitals may recommend preferred SNFs or home health providers but cannot mandate them.

Hospital and physician questions

15. Which hospitals are subject to CJR? Acute care IPPS hospitals in selected MSAs (including Atlanta MSA) that exceed volume thresholds.

16. Can CJR hospitals also participate in BPCI Advanced? For non-MJRLE bundles, yes. For MJRLE, no, CJR takes precedence in CJR MSAs.

17. Is CJR an Advanced APM? Standard CJR participation is not an Advanced APM. A limited Advanced APM CJR pathway exists for hospitals electing higher-risk participation.

18. Does CJR participation provide QP status for physicians? Generally not. Most physicians achieve QP status through MSSP, ACO REACH, or other Advanced APMs.

Geographic questions

19. Which Georgia counties are in the Atlanta MSA? The Atlanta-Sandy Springs-Roswell MSA includes Fulton, DeKalb, Cobb, Gwinnett, Clayton, Cherokee, Henry, Forsyth, Paulding, Douglas, Carroll, Coweta, Newton, Rockdale, Fayette, Spalding, Bartow, Walton, Barrow, and additional surrounding counties.

20. Are Albany, Macon, Savannah, or Gainesville in CJR? No, these are outside the Atlanta MSA and outside CJR's mandatory selection. Hospitals in these areas can participate in BPCI Advanced (voluntarily) but are not in CJR.

Future and successor questions

The Transforming Episode Accountability Model (TEAM), finalized in the CY 2025 IPPS Final Rule. TEAM launches January 1, 2026.

22. How is TEAM different from CJR? TEAM uses a shorter episode than CJR's 90 days, covers multiple clinical categories beyond LEJR, and has three risk tracks.

23. Will the Atlanta MSA be in TEAM? TEAM applies to randomly selected MSAs per the final rule. The CY 2025 IPPS Final Rule contains the list of selected MSAs.

24. What about hospitals that exit CJR before 2025? CJR hospital participation has been continuous in the Atlanta MSA since launch. Hospitals cannot voluntarily exit CJR while it remains mandatory in their MSA.

25. Where can stakeholders learn more? innovation.cms.gov for CJR and TEAM model details. QPP Service Center (1-866-288-8292) for QP/APP questions. Palmetto GBA (1-866-238-9650) for claims processing.

Contact resources

Federal Medicare resources

  • Medicare (general): 1-800-MEDICARE (1-800-633-4227)
  • CMS Innovation Center: innovation.cms.gov
  • QPP Service Center: 1-866-288-8292
  • Palmetto GBA (Part A/B MAC Jurisdiction J): 1-866-238-9650

Georgia state resources

  • GeorgiaCares SHIP: 1-866-552-4464
  • 211 Georgia: 2-1-1
  • Georgia Department of Community Health: dch.georgia.gov
  • Georgia Aging and Disability Resource Connection: 1-866-552-4464

Beneficiary advocacy

  • Medicare Rights Center: 1-800-333-4114
  • Eldercare Locator: 1-800-677-1116
  • Atlanta Legal Aid: 404-377-0701
  • Georgia Legal Services: 1-800-498-9469
  • Acentra Health QIO: 1-844-455-8708

Federal benefit administration

  • Social Security Administration: 1-800-772-1213
  • Benefits Coordination & Recovery Center (BCRC): 1-855-798-2627

Provider/hospital resources

  • Georgia Hospital Association: gha.org
  • Medical Association of Georgia (MAG): mag.org
  • NAACOS: naacos.com
  • American Academy of Orthopaedic Surgeons: aaos.org

Why CJR matters

CJR is the longest-running mandatory CMMI bundled payment model and the operational foundation for everything that follows in Medicare's bundled payment evolution. For nearly a decade, Atlanta MSA hospitals have operated under CJR, and in that time, hip and knee replacement programs across the region have been fundamentally restructured: pre-operative optimization, rapid-recovery protocols, reduced SNF utilization, stronger home health partnerships, and improved care coordination. These operational changes were not voluntary, they were the necessary response to mandatory 90-day episode accountability. As CJR sunsets December 31, 2025 and TEAM takes effect January 1, 2026 with its different design, the lessons of CJR will directly inform how Atlanta hospitals, and Georgia hospitals more broadly, navigate the next phase of bundled payment. CJR's legacy is twofold: a body of operational best practices that has reshaped joint replacement care, and a proof-of-concept that mandatory bundled payment can drive meaningful change in Medicare.

Find personalized help navigating Medicare bundled payment programs at brevy.com.

BC

Brevy Care Team

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