Georgia Medicare CJR Joint Replacement Bundle Guide 2026

If you or a parent faces a hip or knee replacement at an Atlanta-area hospital, the way Medicare paid that hospital changed how the whole surgery is run. Comprehensive Care for Joint Replacement, universally called CJR, was the CMS Innovation Center's flagship mandatory bundled payment model and the longest-running mandatory CMMI bundle in Medicare history. CJR ran from April 1, 2016 through December 31, 2024 across eight performance years 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 held 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. CMS estimated CJR produced about $112.7 million in net Medicare savings while maintaining quality. CJR concluded December 31, 2024 and was succeeded by the mandatory Transforming Episode Accountability Model (TEAM), which began January 1, 2026.

This guide explains how CJR worked, who participated, how Target Prices and reconciliation operated, what CJR meant for Atlanta-area beneficiaries and hospitals, and how CJR relates to BPCI Advanced and its TEAM mandatory successor.

The statutory and regulatory foundation

CJR rested 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 and carried the model through its final performance year, which ended December 31, 2024.
• 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, reflected its mandatory nature. Forcing hospitals to participate in a model required the procedural protections of notice-and-comment rulemaking.

The CJR performance period

CJR operated across eight performance years, from April 1, 2016 through December 31, 2024:

• 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 (final): through December 31, 2024

CJR concluded December 31, 2024; TEAM took 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 (Began January 1, 2026)

The Transforming Episode Accountability Model (TEAM) is the mandatory successor to CJR, finalized in the FY2025 IPPS Final Rule (CMS-1808-F) with refinements in the FY2026 IPPS Final Rule. TEAM began January 1, 2026 and runs through December 31, 2030 (five performance years).

TEAM and Atlanta MSA

• TEAM applies to selected IPPS hospitals in chosen Core-Based Statistical Areas (CBSAs)
• The FY2025 IPPS Final Rule listed the selected geographies
• Atlanta-area inclusion in TEAM is determined by the selection methodology
• Some Georgia hospitals are subject to TEAM regardless of prior CJR participation

TEAM design vs. CJR

TEAM's 30-day 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 generated meaningful Medicare savings across CJR MSAs, with CMS estimating about $112.7 million in net Medicare savings over the model's run, and Atlanta MSA hospitals were among the participating regions that 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 had to plan for the shift to TEAM mandatory participation that began January 1, 2026
14. BPCI Advanced double-bundle prohibition: CJR hospitals cannot include MJRLE under BPCI Advanced

Six Worked Examples: Georgia Medicare Beneficiaries and CJR

The scenarios below illustrate how CJR shaped care during its run (April 1, 2016 through December 31, 2024). The same surgeries performed on or after January 1, 2026 fall under the successor TEAM model where the geography is selected; the geographic and clinical logic the examples illustrate carries forward.

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 during CJR's run. Because the Atlanta MSA was in CJR, the 90-day episode was governed by CJR (not BPCI Advanced, even if Emory participated in BPCI Advanced for other bundles). Emory's pre-operative optimization team prepared her for surgery; she discharged home with home health; outpatient PT followed; 90-day spending was 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 during CJR's run. CJR governed 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 determined 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) during CJR's run. CJR governed. Wellstar's pre-habilitation program prepared him for surgery, pre-op anemia management optimized his blood counts, and a same-day mobilization protocol got him on his feet within hours of surgery. He discharged home with home health on Day 2. 90-day spending came in 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 were not in CJR. The episode followed standard Medicare FFS without CJR bundle accountability. The Albany hospital could 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 was not in CJR. The hospital followed standard Medicare FFS unless it elected 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 were not in CJR. The episode followed standard Medicare FFS or BPCI Advanced if elected.

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

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 was the longest-running mandatory CMMI bundled payment model and the operational foundation for everything that follows in Medicare's bundled payment evolution. From April 1, 2016 through December 31, 2024, Atlanta MSA hospitals operated under CJR, and in that time, hip and knee replacement programs across the region were 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. Now that CJR has concluded and TEAM took effect January 1, 2026 with its different design, the lessons of CJR 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 reshaped joint replacement care, and a proof-of-concept, validated by about $112.7 million in net Medicare savings, that mandatory bundled payment can drive meaningful change in Medicare.

Learn More

• Georgia Medicare CMS Innovation Center (CMMI)
• Georgia Medicare BPCI Advanced
• Georgia Medicare Shared Savings Program (MSSP)
• Georgia Medicare ACO REACH
• Georgia Medicare Skilled Nursing Facility Benefit
• Georgia Medicare Inpatient Rehabilitation Facility (IRF)

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

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