The release of CMS’s new Innovation Center Strategy isn’t just a change in policy; it’s a profound realignment of the entire patient journey. For decades, the healthcare system operated on a fee-for-service (FFS) model, which incentivized volume, i.e. more appointments, more procedures, more spending. As value-based care gains new momentum, we are being asked to look at care not as a series of isolated interventions, but as coordinated, data-informed pathways that deliver demonstrably better results at lower costs.
For rehab professionals – Physical Therapists (PTs), Occupational Therapists (OTs), and Speech-Language Pathologists (SLPs) – this transition is both a challenge and a massive opportunity. Our work inherently focuses on function, prevention, and independence, which are the cornerstones of the new CMS vision. However, many rehab care plans are still too fragmented, too reactive, and too disconnected from the broader ecosystem of care, often operating in a silo. This won’t cut it in this next, more accountable phase of transformation.
The new mandate: prevention, empowerment, and value accountability
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The new CMS Innovation Strategy is built on three pillars: Promote evidence-based prevention, Empower people to achieve their health goals, and Drive choice and competition. For rehab providers, these pillars translate directly into a necessity for rigorously structured and measured care pathways.
The risk has never been higher for ignoring this shift. Future payment models, like the recently proposed Ambulatory Specialty Model (ASM), will place specialists under two-sided financial risk for episode costs and quality outcomes related to high-volume, high-cost conditions like low back pain and heart failure. These models specifically penalize low-value care, which often means avoiding unnecessary advanced imaging, injections, and, critically, non-evidence-based interventions that do not contribute to functional improvement.
Rehab’s opportunity is clear: By optimizing our care pathways, we can serve as the primary cost-savings intervention, demonstrating that functional rehabilitation is the evidence-based alternative to unnecessary downstream utilization, including surgery.
Redefining the rehab care pathway
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Care pathways are, in essence, the maps we follow to get patients from functional limitation to functional independence. Optimizing them requires a multi-faceted approach centered on clinical effectiveness and operational efficiency. Here is what that means for rehab performance:
1. Standardization where it matters: anchoring to clinical evidence
The foundation of an optimized pathway is standardization. This doesn’t mean treating every patient the same, but rather defining shared protocols for common conditions (e.g., total joint replacement recovery, stroke rehabilitation, or chronic low back pain) that are built on objective outcomes data and nationally recognized Clinical Practice Guidelines (CPGs).
In the low back pain space, for instance, a standardized pathway must prioritize early, evidence-based physical therapy while actively reducing reliance on passive modalities, excessive imaging (like unnecessary MRIs, which is a specific measure in ASM), and high-risk medications. This systematic adherence to a low-cost, high-value sequence is the key to managing episode costs and achieving shared savings under new CMMI arrangements.
2. Customization where it counts: leveraging functional expertise
While standardization sets the boundary lines for high-value care, customization is where the distinct expertise of the rehab professional shines. Protocols must still allow for flexibility based on individual patient profiles, goals, comorbidities, and Social Determinants of Health (SDOH).
The ability of a therapist to personalize care within a structured framework is our unique value proposition. Customization is not an excuse for variation; it is the thoughtful application of standardized interventions to achieve the patient’s individual goals, often tracked using Patient-Reported Outcome Measures (PROMs).
3. Strategic sequencing: Embedding rehab upstream
In the value-based era, rehab must be proactively positioned. Strategic “sequencing” is about proactively defining where we fit in the full care journey:
- Upstream (prevention): Engaging high-risk patients (e.g., those with pre-diabetes, early signs of frailty, or a history of falls) before an acute event occurs. This directly addresses CMS’s goal of prevention and avoids high-cost institutional care.
- During (episode management): Integrating functional measurement into every appropriate stage to track progress and justify the next step, ensuring interventions are timely and necessary.
- Downstream (transitions): Coordinating closely with primary care, specialists, and community resources to ensure smooth transitions of care, reducing the risk of readmission or exacerbation of chronic conditions. This enhanced collaboration is explicitly incentivized by Improvement Activities in models like ASM.
The call to action: Defining our own success
This is where operational maturity meets clinical excellence. We cannot wait for CMS to hand us perfect blueprints for rehab. The time is now for rehab leaders to define what optimized care looks like, build these pathways using evidence and outcomes data, and then aggressively demonstrate that our services are the most effective way to align with the new strategic direction of healthcare. By leading with measured value, we secure our essential role in value-based arrangements and prove, definitively, that outcomes are the strategy, not just the scorecard.
Photo: Arturo Peña Romano Medina, Getty Images
Susan Lofton is a physical therapist with 25 years of experience in clinical care, operations, and senior-level management. Susan has worked in multiple healthcare settings including acute, IRF, skilled nursing, home health and outpatient, giving her exceptional insight into the transitional needs of patients and the inner workings of the healthcare ecosystem. Susan is passionate about improving health care and has deep expertise in regulatory compliance and optimizing strategies for success. Susan serves as VP, Outcomes and Clinical Transformation for WebPT and is ED of Keet Outcomes Qualified Clinical Data Registry (QCDR) for participation in MIPS and other quality payment programs.
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