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A fter years of planning, on April 1, 2016 the Centers for Medicare & Medicaid Services (CMS) rolled out its Comprehensive Care for Joint Replacement (CJR) program. The CJR program is based on a so-called bundled payment system, one that ‘‘holds participant hospitals financially accountable for the quality and cost of care... and incentivizes increased coordination of care among hospitals, physicians, and post-acute care providers’’ [4]. The CJR program establishes a spending target for knee and hip replacements for each participating hospital. At the end of each year, CMS plans to compare the hospital’s actual spending to the target and ‘‘depending on the participant hospital’s quality and episode spending performance, the hospital may receive an additional payment from Medicare or be required to repay Medicare for a portion of the episode spending’’ [4]. The ultimate effectiveness of the CJR program remains to be seen. I personally doubt that price controls do much to limit spending [3]. Yet at the least, the program rests on an intuitively appealing rationale: Accountability for outcomes and spending. Across the United States, there is at least a two-fold variance in the mean costs for providing joint replacement services, and there is a three-fold variance in the frequency of complications. A bundled payment gives less-efficient hospitals a strong financial incentive—some ‘‘skin in the game’’—to emulate their more-efficient peers. Arthroplasty for arthritis is perhaps the most apt procedure to reap benefits from a bundled payment approach. Arthroplasty is a high-cost item for Medicare (about USD 7 billion a year for hospitalizations alone [4]), and it is distinctly open to standardization. But Medicare did not stop at arthroplasty for arthritis. The CJR also includes hip arthroplasty done for fracture as well. This is a bad idea. Comingling hip arthroplasty done for fracture with arthroplasty for arthritis is unsound on at least two counts. First, few hospitals, if any, perform arthroplasty for fracture in sufficient numbers to master what CMS calls the ‘‘coordination of care’’ issues that can meaningfully decrease costs. Second, unlike patients treated for hip arthritis, whose medical comorbidities can be ameliorated before the patients’ elective admission, patients admitted for hip fracture come in urgently, and often in distress. At one level, Medicare acknowledges that hip fracture patients are not comparable to arthritis patients—the payments for fracture cases are substantially larger. But that is not Note from the Editor-in-Chief: We are pleased to present to readers of Clinical Orthopaedics and Related Research the next Not the Last Word. The goal of this section is to explore timely and controversial issues that affect how orthopaedic surgery is taught, learned, and practiced. We welcome reader feedback on all of our columns and articles; please send your comments to eic@clinorthop.org. The author certifies that he, or any member of his immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/ licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of Clinical Orthopaedics and Related Research or The Association of Bone and Joint Surgeons.

Not the Last Word: Learned Helplessness and Medicare's Bungled Bundled Payment Program