By Eme Augustini, Policy Director, Thought Leadership, Press Ganey
OAS CAHPS has been part of the CMS quality landscape for a decade and became mandatory for hospital outpatient departments in 2024. Under the mandatory framework, the financial stakes have been tied to participation: report data or face a reduction in your Medicare payment update. A hospital’s performance relative to its peers has carried no direct financial consequence.
CMS is proposing to change that.
The Comprehensive Care for Joint Replacement Expanded (CJR-X) model, included in the FY 2027 IPPS proposed rule, would make patient experience scores a direct factor in hospital payment for joint replacement episodes. Most significantly, it would mark the first time OAS CAHPS is used in a pay-for-performance framework, which represents a meaningful shift for a measure that has existed in a pay-for-reporting context since its mandatory implementation. For quality and patient experience leaders at hospitals performing hip, knee, and ankle replacements, understanding the model’s mechanics and timeline is worth doing now, before the proposed October 2027 start date.
What is CJR-X?
CJR-X would be a mandatory national model covering lower extremity joint replacements (LEJR) at most acute care hospitals. Under the model, the hospital where surgery occurs is accountable for all Medicare Part A and B spending during the episode, from the initial procedure through 90 days post-discharge.
Hospitals earn a reconciliation payment if their actual episode spending comes in below a target price or owe a repayment if they exceed it — two-sided risk from the start with quality performance woven directly into the financial calculation.
Patient experience accounts for 40% of the quality score
CJR-X uses a Composite Quality Score (CQS), built from five quality measures across three domains, to set a “discount factor” that adjusts each hospital’s reconciliation target price. That discount ranges from 0% to 2%, functioning as a headwind that quality performance can reduce—excellent performers face no effective discount at reconciliation, while lower tiers retain all or part of it.
Patient experience carries 40% of the weight in the CQS, split across two settings:
- Inpatient episodes: HCAHPS (pulled from existing IQR reporting)
- Outpatient episodes: OAS CAHPS (pulled from existing OQR reporting)
The remaining weight goes to measures of complications (50%) and patient-reported outcomes (10%). The inpatient and outpatient composites are then combined into an overall CQS weighted by each hospital’s actual share of inpatient versus outpatient LEJR volume.
| Quality domain | Quality measure: Inpatient | Quality measure: Outpatient | Weight |
| Complications | Hospital-level RSCR following elective primary THA and/or TKA | Hospital visits within 7 days of HOPD surgery | 50% |
| Patient experience | HCAHPS | OAS CAHPS | 40% |
| Patient-reported outcomes | THA/TKA PRO-Based Performance Measure (PRO-PM) | THA/TKA PRO-Based Performance Measure (PRO-PM) | 10% |
Quality performance then determines which of four CQS tiers a hospital lands in, as well as what discount factor applies:
| Tier | CQS range | Discount factor |
| Excellent | ≥ 17.1 pts | 0% discount |
| Good | 12.1–17.0 pts | 1% discount |
| Acceptable | 6.1–12.0 pts | 2% discount |
| Below acceptable | ≤ 6.0 pts | 2% + ineligible for reconciliation payment |
Hospitals in the “below acceptable” tier face the steepest consequence: They can’t receive a reconciliation payment at all, even if their episode spending falls below the target price.
This marks the first time OAS CAHPS is used in pay for performance
HCAHPS has long been embedded in pay for performance through the Hospital Value-Based Purchasing (VBP) program. OAS CAHPS has not. CJR-X would bring OAS CAHPS into that same territory for the first time, making a hospital’s relative performance on the measure (not just its participation) financially consequential.
Under the proposed model, both HCAHPS and OAS CAHPS percentile rankings on the national distribution translate directly into points that flow into the CQS and, ultimately, into the discount factor applied at reconciliation. The scoring methodology works the same way for both surveys: A hospital’s raw result (drawn from its broader reported survey population, not just joint replacements) is placed on the national distribution of IPPS-eligible hospitals and assigned points based on percentile tier, up to a maximum of 8 points for the patient experience domain.
| Performance percentile | Hospital-level RSCR following elective primary THA and/or TKA | Hospital visits within 7 days of HOPD surgery | HCAHPS Survey | OAS CAHPS Survey | Hospital-level THA/TKA PRO-PM |
| ≥90th | 10.00 | 10.00 | 8.00 | 8.00 | 2.00 |
| ≥80th and <90th | 9.25 | 9.25 | 7.40 | 7.40 | 1.85 |
| ≥70th and <80th | 8.50 | 8.50 | 6.80 | 6.80 | 1.70 |
| ≥60th and <70th | 7.75 | 7.75 | 6.20 | 6.20 | 1.55 |
| ≥50th and <60th | 7.00 | 7.00 | 5.60 | 5.60 | 1.40 |
| ≥40th and <50th | 6.25 | 6.25 | 5.00 | 5.00 | 1.25 |
| ≥30th and <40th | 5.50 | 5.50 | 5.40 | 5.40 | 1.10 |
| <30th | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
Note: The proposed rule assigns 5.40 points to the 30th–40th percentile tier for PX-based measures, which is higher than the 5.00 points for the 40th–50th percentile tier, an apparent drafting error that CMS may correct in the future.
The percentile approach means performance is evaluated relative to the national field. Because CMS proposes a sliding historical baseline that updates annually, the threshold for a given percentile tier can shift as the field broadly improves. Holding steady in absolute score terms may not be enough to maintain a percentile position over the life of the model.
Why OAS CAHPS carries particular weight in this model
Including HCAHPS in payment models is not new. OAS CAHPS entering pay for performance is, and its implications run deeper than simply adding a second survey to the scorecard.
The inpatient and outpatient CQS components are weighted by a hospital’s actual proportion of inpatient versus outpatient LEJR episodes. According to CMS’s Seventh Annual Evaluation of the original CJR model, outpatient procedures accounted for nearly three in four THA and TKA episodes by the end of that model. For hospitals where outpatient volume now dominates, OAS CAHPS will carry more weight in the overall CQS than HCAHPS.
There is also a practical threshold issue specific to OAS CAHPS. To receive a scored result under CJR-X rather than a default 50th percentile assignment, a hospital must have at least 100 completed OAS CAHPS surveys in the national distribution. This is higher than the standard public reporting threshold for OAS CAHPS, which requires as few as 25 completed surveys. Hospitals that hover near the lower end of their typical survey volume face the prospect of being placed at the national midpoint regardless of how their actual performance compares, a meaningful consideration for programs where outpatient surgical volume is moderate. Hospitals not currently participating in the OQR Program will have no OAS CAHPS data available for CJR-X scoring and will receive the same 50th percentile default.
One more nuance: The first performance year’s quality data is collected before the model even begins
For Performance Year 1 (PY1), the quality data that determines a hospital’s discount factor will be drawn from calendar year 2027 starting in January 2027, even though the model doesn’t begin until October of that year. Most of a hospital’s PY1 quality score will, therefore, be shaped by patient experience performance accumulated well before the first CJR-X episode is initiated. Starting in PY 2, the measurement window advances to CY 2028, aligning more closely with actual model performance.
What this means for your organization
CJR-X is still a proposed rule, with a comment period closing June 9, 2026, and details may change before finalization. Submitting comments is one concrete action hospitals can take now, particularly on aspects of the quality methodology where the proposed rule seeks stakeholder input.
Beyond commenting, a few practical questions are worth working through:
- Are you participating in the OQR Program and administering OAS CAHPS? Participation now builds operational experience that will matter as OAS CAHPS enters pay-for-performance territory under CJR-X.
- Do you know where you stand on the national distribution? Understanding your current OAS CAHPS and HCAHPS percentiles and how close you are to key scoring tier thresholds is the starting point for any financial modeling under CJR-X.
- What is your outpatient LEJR volume share? The higher that proportion, the more your overall CQS will be shaped by OAS CAHPS performance (versus HCAHPS).
- Is your OAS CAHPS survey volume consistently above 100? Anything below that threshold means defaulting to the 50th percentile regardless of actual performance.
Press Ganey works with hospitals across the country on HCAHPS and OAS CAHPS measurement, administration, and quality improvement—including benchmarking that provides visibility into where your performance sits relative to peers. As CJR-X moves toward finalization, that perspective can inform both your understanding of the model and your operational planning.
Questions about measuring patient experience in the outpatient setting? Reach out to a Press Ganey expert here.
Disclaimer: This content is intended to provide a summary of the proposed CJR-X model as it relates to patient experience measurement. It is not exhaustive and does not constitute legal or regulatory advice. CMS proposed rule details are subject to change through the rulemaking process.