Impact of the Comprehensive Care for Joint Replacement Model on Spending and Care Endpoints: A Systematic Review.

Abstract

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. 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. 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. 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.