CMS just made one of the most consequential orthopedic payment decisions in years, and every surgeon, hospital, and surgery center involved in total joints should pay attention. The Comprehensive Care for Joint Replacement Expanded Model, or CJR-X, has now been finalized as a mandatory nationwide model beginning January 1, 2028 for most eligible hospitals. It covers Medicare hip, knee, and ankle replacements and makes the hospital financially accountable not merely for the operation, but for the entire episode through 90 days after discharge.

The numbers behind the decision are worth noting. The original CJR model operated in only 34 metropolitan areas. CMS reports that its evaluation of performance years 2021 through 2023 found approximately $112.7 million in net Medicare savings while maintaining quality. CJR-X takes that experiment and turns it into national policy. Episodes can be triggered by inpatient MS-DRGs 469, 470, 521 and 522, as well as hospital outpatient total knee arthroplasty, HCPCS 27447, and total hip arthroplasty, HCPCS 27130. CMS will compare actual episode spending against a target price. Beat the target while meeting quality standards and a hospital can receive reconciliation money. Miss it and money can flow the other direction.

Here is where surgery centers should become interested. ASCs are not the accountable entity under CJR-X, but the economic gravity surrounding total joints is changing. Hospitals will have enormous incentive to control complications, readmissions, rehabilitation utilization, emergency visits and every other dollar spent during those 90 days. That makes efficient surgeons, predictable pathways and low-cost outpatient delivery increasingly valuable partners.

CJR-X also uses 29 risk adjusters, far more than the three used in the original CJR model. Hospitals participating in TEAM are excluded while TEAM remains in effect. CMS is essentially building two giant laboratories at once: TEAM with a 30-day episode and CJR-X with a 90-day episode.

For orthopedic surgeons, the message is simple. The operation may last an hour. Medicare is increasingly paying attention to what happens for months afterward.