The Journal of Arthroplasty , Volume 33 , Issue 9 , 2722 - 2727

Are Medicare’s “Comprehensive Care for Joint Replacement” Bundled Payments Stratifying Risk Adequately?

Cairns, Mark A. et al.
Hip Knee


Bundled payments are meant to reduce costs and improve quality of care. Without adequate risk adjustment, bundling may be inequitable to providers and restrict access for certain patients. This study examines patient factors that could improve risk stratification for the Comprehensive Care for Joint Replacement (CJR) bundled-payment program.


Ninety-five thousand twenty-four patients meeting the CJR criteria were retrospectively reviewed using administrative Medicare data. Multivariable regression was used to identify associations between patient factors and traditional (fee-for-service) Medicare reimbursement over the bundle period.


Average reimbursement was $18,786 ± $12,386. Older age, male gender, cases performed for hip fractures, and most comorbidities were associated with higher reimbursement (P < .05), except dementia (lower reimbursement; P < .01). Stratification incorporating these factors displayed greater accuracy than the current CJR risk adjustment methods (R2 = 0.23 vs 0.17).


More robust risk stratification could provide more equitable reimbursement in the CJR program.

Level of Evidence

Large database analysis; Level III.

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