Between-Community Low-Income Status and Inclusion in Mandatory Bundled Payments in Medicare’s Comprehensive Care for Joint Replacement Model

Using a market-level mandate, Medicare’s Comprehensive Care for Joint Replacement (CJR) Model has required urban US hospitals to accept bundled payments for hip and knee surgery episodes. Among metropolitan statistical area (MSA) markets with above-average episode spending (196 of 384 MSAs), Medicare randomly selected 67 for inclusion.¹ Given the 3% to 4% episode savings and stable quality achieved through CJR, Medicare has reinforced its commitment to MSA market-level mandates, using the approach in the forthcoming Radiation Oncology Model with another mandatory program planned in 2023.^2,3

One key advantage of mandatory over voluntary programs is mitigating physician or hospital self-selection that could lead to the exclusion of patients with low socioeconomic status (SES).⁴ This advantage can also enhance generalizability of program results, but only if regions in the program do not differ greatly from those not included. However, it remains unclear whether communities in CJR are representative of others nationwide with respect to residents’ SES.