Secretary Robert F. Kennedy, Jr
U.S. Department of Health & Human Services
200 Independence Avenue SW
Washington, DC 20201
The Honorable Administrator Mehmet Oz, M.D.
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244
June 9, 2026
Re: Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2027 Rates; Requirements for Quality Programs; and Other Policy Changes (CMS-1849-P; RIN: 0938-AV79)
Dear Secretary Kennedy and Administrator Oz:
On behalf of Accountable for Health, we appreciate the opportunity to provide feedback on concepts included in the Fiscal Year (FY) 2027 Hospital Inpatient Prospective Payment System (IPPS) proposed rule, specifically the Comprehensive Care for Joint Replacement Expanded (CJR-X) Model and the Transforming Episode Accountability Model (TEAM).
Accountable for Health is a non-partisan, national advocacy and policy organization accelerating the adoption of effective accountable care. We aim to inform policy that advances the movement in the health care system toward accountable care that achieves better outcomes, improved care experiences, increased access and lower costs.
Primary care-centered total cost of care models, such as accountable care organizations (ACOs), have served as the backbone of accountable care delivery system reform efforts to date.1 Recent episode-based payment reforms have focused on acute events (e.g., heart attacks) and major procedures (e.g., joint replacements), representing a small component of the impact specialists have on health care outcomes, experiences and costs.2 These models have made progress toward creating a more holistic approach to payment and health care delivery, but more can be done to create an integrated specialty care strategy that aligns toward whole person care.
Our specific comments on the CJR-X Model are provided below. A4H believes that immediately deploying longitudinal approaches that integrate specialty care models with total cost of care models will best serve people and providers.
Episode-Based Payment Models Improve Care, Lower Costs
As noted in the proposed rule, the CMS Innovation Center has substantial experience with episode-based payment models, including the Comprehensive Care for Joint Replacement (CJR) model, Bundled Payments for Care Improvement (BPCI), Bundled Payments for Care Improvement Advanced (BPCI-A) and now with the Transforming Episode Accountability Model (TEAM) and the proposed expansion of the CJR Model.
Experience with episode-based payment models demonstrates that these models can improve care coordination, expand access to services including those that address social need, and lower costs.3 Episode-based accountability can create a structure that lends itself toward greater levels of accountable care, including more familiarity with data and responsibility for care management, experiences and outcomes across settings. CMS’s evaluations show that providers undertook efforts such as developing discharge plans, engaging patients in care plans, following-up with patients, tracking patient outcomes post-discharge, and communicating with post-acute care providers about patient care.4
Support for Mandatory Models After Sufficient Testing of Voluntary Options
We commend the CMS Innovation Center for carefully evaluating what has worked in previous demonstrations and incorporating those lessons learned in this new proposed model. We support testing mandatory models after sufficient voluntary model options have been created and providers have had an opportunity to elect participation. A targeted, specific mandatory model provides opportunities to engage providers on the glidepath to risk who have not yet engaged, create meaningful learnings for the future of delivery system transformation, and have the potential to be expanded if it is successful. Clinicians and entities participating in voluntary total cost of care models in a meaningful way should be exempt from mandatory models. Creating such an exemption is another powerful incentive for voluntary participation in total cost of care models.
For these reasons, A4H supports the mandatory structure of CJR-X as a mechanism for enabling providers to get on a glidepath to accountable care. We believe this is consistent with what was originally intended for value-based payment reform and that mandatory models could create a foundation for understanding how episode-based accountability can be structured and expanded in the future.
Specific Comments on Proposed CJR-X Model
We appreciate CMS’s continued engagement with stakeholders as the model is refined and reiterate our strong belief that model policies should be aligned where appropriate and that mid-model changes should be minimized to the extent possible to provide stability and predictability for participating hospitals.
Participation Tracks
CMS proposes that all participants in CJR-X take two-sided risk for 90-day episodes of care. This approach differs from the TEAM model, which includes a range of participation options including time-limited, upside only risk options.
A4H is concerned about the proposed mandatory two-sided risk track for safety net hospitals. Many safety-net, rural and critical access hospitals have closed due to financial distress. We are concerned that they may not be ready to undertake two-sided risk models without experience with upside only models. We recommend that the agency consider making their participation in two-sided risk optional.
Model Overlaps
CMS proposes to permit overlap with CJR-X and total cost of care or shared savings models or programs. Aligned with the approach in the TEAM Model, CMS proposes to allow any savings generated on an episode in CJR-X and any contribution to savings in the total cost of care model be retained by each respective participant in the reconciliation process. A4H supports this proposed approach to model overlaps and appreciates the agency’s efforts to ensure greater harmonization across models.
We recommend that CMS allow ACOs that are participating in two-sided risk, such as Medicare Shared Savings Program ENHANCED or the Long-term Enhanced ACO Design (LEAD) Model be permitted to have their participating hospitals opt out of CJR-X. This would create an additional incentive for participation in two-sided risk total cost of care models and recognize that these entities are already accountable for cost and health outcomes for their population.
Discount
CMS propose to apply a 2% discount factor to the benchmark price to serve as Medicare’s portion of reduced expenditures from the episode.
A4H believes that a 2% discount is too high for this mandatory model and encourages CMS to reduce the discount to no more than 1%. We are particularly concerned about a 2% discount in the context of rural and safety net hospitals. In addition, for hospitals that have previously participated in BPCI Advanced or CJR, CMS should account for the reduction in costs that have already been achieved. This could be done by applying shared savings for those episodes and not using a discount or by removing these episodes from the model for those participants.
Primary Care Referral
Unlike the TEAM Model, CJR-X does not include a primary care referral requirement, likely in part because of the extended length of the episode. A4H supports incentives to connect patients to a longitudinal primary care relationship and believe that CMS should adopt additional safeguards to ensure that patients who are already aligned to a provider be “tucked back in” to that provider. For example, CMS could consider including care coordination warm hand off CPT II codes like the Advanced Care Planning (ACP) code included as a BPCI Advanced ACP quality measure. In the case of a provider in an ACO, CJR-X can create an opportunity for collaboration between the hospital and the ACO to improve care transitions and ensure longitudinal care strategies.
Accountable for Health appreciates the opportunity to provide comments on the proposed rule. If you have any questions about our comments or need more information, please do not hesitate to contact Mara McDermott, mmcdermott@accountableforhealth.org.
Sincerely,
Mara McDermott
CEO
Accountable for Health
1 We note that CMS indicates it is not seeking feedback on models that address conditions over a longer period of time such as the Enhancing Oncology Model and the Kidney Care Choices model. These models continue to be important elements of the agency’s accountable care strategy and we look forward to continued engagement on these topics as well.
2 Strengthening Specialist Participation in Comprehensive Care through Condition-Based Payment Reforms, Duke Margolis (November 2022), available at https://healthpolicy.duke.edu/publications/strengthening-specialist-participation-comprehensive-care-through-condition-based
3 In December 2025, the CMS Innovation Center released the CMS CJR Model: Performance Year 7 Evaluation Report and found that the model resulted in estimated savings of $112.7 million (M) across PYs 6–7. It also found that the model resulted in estimated savings of $58.8 M in PY 7, continuing a pattern of savings from PY 6. Comprehensive Care for Joint Replacement Model—Seventh Annual Report ( https://www.cms.gov/priorities/innovation/data-and-reports/2025/cjr-py7-annual-report).
4 CMS Comprehensive Care for Joint Replacement Model: Performance Year 5 Evaluation Report, The Lewin Group (April 2023).
Secretary Robert F. Kennedy, Jr
U.S. Department of Health & Human Services
200 Independence Avenue SW
Washington, DC 20201
The Honorable Administrator Mehmet Oz, M.D.
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244
June 9, 2026
Re: Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2027 Rates; Requirements for Quality Programs; and Other Policy Changes (CMS-1849-P; RIN: 0938-AV79)
Dear Secretary Kennedy and Administrator Oz:
On behalf of Accountable for Health, we appreciate the opportunity to provide feedback on concepts included in the Fiscal Year (FY) 2027 Hospital Inpatient Prospective Payment System (IPPS) proposed rule, specifically the Comprehensive Care for Joint Replacement Expanded (CJR-X) Model and the Transforming Episode Accountability Model (TEAM).
Accountable for Health is a non-partisan, national advocacy and policy organization accelerating the adoption of effective accountable care. We aim to inform policy that advances the movement in the health care system toward accountable care that achieves better outcomes, improved care experiences, increased access and lower costs.
Primary care-centered total cost of care models, such as accountable care organizations (ACOs), have served as the backbone of accountable care delivery system reform efforts to date.1 Recent episode-based payment reforms have focused on acute events (e.g., heart attacks) and major procedures (e.g., joint replacements), representing a small component of the impact specialists have on health care outcomes, experiences and costs.2 These models have made progress toward creating a more holistic approach to payment and health care delivery, but more can be done to create an integrated specialty care strategy that aligns toward whole person care.
Our specific comments on the CJR-X Model are provided below. A4H believes that immediately deploying longitudinal approaches that integrate specialty care models with total cost of care models will best serve people and providers.
Episode-Based Payment Models Improve Care, Lower Costs
As noted in the proposed rule, the CMS Innovation Center has substantial experience with episode-based payment models, including the Comprehensive Care for Joint Replacement (CJR) model, Bundled Payments for Care Improvement (BPCI), Bundled Payments for Care Improvement Advanced (BPCI-A) and now with the Transforming Episode Accountability Model (TEAM) and the proposed expansion of the CJR Model.
Experience with episode-based payment models demonstrates that these models can improve care coordination, expand access to services including those that address social need, and lower costs.3 Episode-based accountability can create a structure that lends itself toward greater levels of accountable care, including more familiarity with data and responsibility for care management, experiences and outcomes across settings. CMS’s evaluations show that providers undertook efforts such as developing discharge plans, engaging patients in care plans, following-up with patients, tracking patient outcomes post-discharge, and communicating with post-acute care providers about patient care.4
Support for Mandatory Models After Sufficient Testing of Voluntary Options
We commend the CMS Innovation Center for carefully evaluating what has worked in previous demonstrations and incorporating those lessons learned in this new proposed model. We support testing mandatory models after sufficient voluntary model options have been created and providers have had an opportunity to elect participation. A targeted, specific mandatory model provides opportunities to engage providers on the glidepath to risk who have not yet engaged, create meaningful learnings for the future of delivery system transformation, and have the potential to be expanded if it is successful. Clinicians and entities participating in voluntary total cost of care models in a meaningful way should be exempt from mandatory models. Creating such an exemption is another powerful incentive for voluntary participation in total cost of care models.
For these reasons, A4H supports the mandatory structure of CJR-X as a mechanism for enabling providers to get on a glidepath to accountable care. We believe this is consistent with what was originally intended for value-based payment reform and that mandatory models could create a foundation for understanding how episode-based accountability can be structured and expanded in the future.
Specific Comments on Proposed CJR-X Model
We appreciate CMS’s continued engagement with stakeholders as the model is refined and reiterate our strong belief that model policies should be aligned where appropriate and that mid-model changes should be minimized to the extent possible to provide stability and predictability for participating hospitals.
Participation Tracks
CMS proposes that all participants in CJR-X take two-sided risk for 90-day episodes of care. This approach differs from the TEAM model, which includes a range of participation options including time-limited, upside only risk options.
A4H is concerned about the proposed mandatory two-sided risk track for safety net hospitals. Many safety-net, rural and critical access hospitals have closed due to financial distress. We are concerned that they may not be ready to undertake two-sided risk models without experience with upside only models. We recommend that the agency consider making their participation in two-sided risk optional.
Model Overlaps
CMS proposes to permit overlap with CJR-X and total cost of care or shared savings models or programs. Aligned with the approach in the TEAM Model, CMS proposes to allow any savings generated on an episode in CJR-X and any contribution to savings in the total cost of care model be retained by each respective participant in the reconciliation process. A4H supports this proposed approach to model overlaps and appreciates the agency’s efforts to ensure greater harmonization across models.
We recommend that CMS allow ACOs that are participating in two-sided risk, such as Medicare Shared Savings Program ENHANCED or the Long-term Enhanced ACO Design (LEAD) Model be permitted to have their participating hospitals opt out of CJR-X. This would create an additional incentive for participation in two-sided risk total cost of care models and recognize that these entities are already accountable for cost and health outcomes for their population.
Discount
CMS propose to apply a 2% discount factor to the benchmark price to serve as Medicare’s portion of reduced expenditures from the episode.
A4H believes that a 2% discount is too high for this mandatory model and encourages CMS to reduce the discount to no more than 1%. We are particularly concerned about a 2% discount in the context of rural and safety net hospitals. In addition, for hospitals that have previously participated in BPCI Advanced or CJR, CMS should account for the reduction in costs that have already been achieved. This could be done by applying shared savings for those episodes and not using a discount or by removing these episodes from the model for those participants.
Primary Care Referral
Unlike the TEAM Model, CJR-X does not include a primary care referral requirement, likely in part because of the extended length of the episode. A4H supports incentives to connect patients to a longitudinal primary care relationship and believe that CMS should adopt additional safeguards to ensure that patients who are already aligned to a provider be “tucked back in” to that provider. For example, CMS could consider including care coordination warm hand off CPT II codes like the Advanced Care Planning (ACP) code included as a BPCI Advanced ACP quality measure. In the case of a provider in an ACO, CJR-X can create an opportunity for collaboration between the hospital and the ACO to improve care transitions and ensure longitudinal care strategies.
Conclusion
Accountable for Health appreciates the opportunity to provide comments on the proposed rule. If you have any questions about our comments or need more information, please do not hesitate to contact Mara McDermott, mmcdermott@accountableforhealth.org.
Sincerely,
Mara McDermott
CEO
Accountable for Health
1 We note that CMS indicates it is not seeking feedback on models that address conditions over a longer period of time such as the Enhancing Oncology Model and the Kidney Care Choices model. These models continue to be important elements of the agency’s accountable care strategy and we look forward to continued engagement on these topics as well.
2 Strengthening Specialist Participation in Comprehensive Care through Condition-Based Payment Reforms, Duke Margolis (November 2022), available at https://healthpolicy.duke.edu/publications/strengthening-specialist-participation-comprehensive-care-through-condition-based
3 In December 2025, the CMS Innovation Center released the CMS CJR Model: Performance Year 7 Evaluation Report and found that the model resulted in estimated savings of $112.7 million (M) across PYs 6–7. It also found that the model resulted in estimated savings of $58.8 M in PY 7, continuing a pattern of savings from PY 6. Comprehensive Care for Joint Replacement Model—Seventh Annual Report ( https://www.cms.gov/priorities/innovation/data-and-reports/2025/cjr-py7-annual-report).
4 CMS Comprehensive Care for Joint Replacement Model: Performance Year 5 Evaluation Report, The Lewin Group (April 2023).
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