JOA - 2026-07-14 - Journal Article; Review
Impact of the Comprehensive Care for Joint Replacement Model on Spending and Care Endpoints: A Systematic Review.
Sontag-Milobsky I, Knebel R, Edelstein AI, Ricciardi B, Rosenthal M, McGarry B, Suleiman LI, Thirukumaran CP
Topics
Key Takeaway
The CJR bundled-payment model reduced 90-day episode spending by $469–$1,322 per THA/TKA episode primarily through reduced skilled-nursing facility utilization, but generated measurable racial and socioeconomic disparities in access.
Summary Depth
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Summary
This PRISMA-compliant systematic review (PROSPERO CRD42024596111) evaluated 23 quasi-experimental Medicare claims studies examining the CJR model's effect on spending, outcomes, discharge disposition, and utilization from 2016–2024. Ten of 16 cost-reporting studies demonstrated episode savings of $469–$1,322, driven by reduced institutional post-acute care; most studies found no increase in 90-day complications or mortality. Eight studies identified a shift toward home discharge, but multiple analyses flagged declining procedure rates among Black beneficiaries and in socioeconomically disadvantaged areas, indicating adverse distributional effects.
Key Limitation
All 23 included studies are observational Medicare claims analyses, making it impossible to isolate CJR effects from concurrent policy changes (e.g., BPCI-A, mandatory bundled payment pilots) that affected the same institutions and time periods.
Original Abstract
BACKGROUND
The Centers for Medicare & Medicaid Services implemented the Comprehensive Care for Joint Replacement (CJR) bundled-payment model (2016 to 2024) to improve value for total hip and knee arthroplasty (THA/TKA). We systematically reviewed the model's impact on episode spending, clinical outcomes, discharge destination, and total joint arthroplasty (TJA) utilization.
METHODS
Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (PROSPERO CRD42024596111), we searched PubMed, Embase, and Web of Science (January 2015 to September 2024) for English-language studies comparing outcomes before versus after CJR. There were two reviewers who independently screened records, extracted prespecified variables, and synthesized findings by domain. Risk of bias for nonrandomized studies was assessed with a validated risk of bias tool.
RESULTS
There were 23 studies included, predominantly quasi-experimental Medicare claims analyses (2011 to 2020) encompassing millions of THA/TKA episodes. Of 16 studies that assessed 90-day costs, 10 reported major savings (mean estimated spending reductions ranged from $469 to $1,322 per episode), largely from reduced institutional post-acute care, especially skilled-nursing facilities. Some analyses suggested diminishing savings over time and limited net savings after reconciliation. Most studies found no increase in 90-day complications or mortality, with several reporting small reductions in readmissions. Lengths of stay decreased modestly in some settings. There were eight studies that had lower discharge to institutional post-acute care and greater home or home-health usage, often with fewer visits. Multiple analyses suggested patient selection favoring lower-risk, younger, and White patients; procedure rates declined among Black beneficiaries and in socioeconomically disadvantaged areas. Overall risk of bias was commonly low to moderate given observational designs.
CONCLUSIONS
The CJR achieved meaningful, primarily post-acute-care-driven reductions in episode spending without broad deterioration in clinical outcomes. Evidence of patient selection and widening disparities, however, suggests that the policy engendered adverse distributional effects. Future episode-based reforms should incorporate social risk adjustment and guardrails to preserve access and equitable benefit alongside cost containment.