Pulmonary Rehab Program Capacity: Extending Beyond Hospital Walls

Key Takeaways
The United States has about 1,696 pulmonary rehab centers for 10.2 million Medicare beneficiaries with COPD, roughly one center for every 6,030 patients, in the most recent national analysis (2018 claims, published 2023). Cardiac rehab has nearly 2,500 programs for a smaller eligible pool.

Supply is one barrier alongside referral practice and patient factors: only about 1.5% of Medicare COPD patients start pulmonary rehab within 90 days of discharge, and more than half of US counties have no hospital-based outpatient program. No national trend series exists; the one published series, from the Veterans Health Administration, fell from 125 center-based sites in 2018 to 33 in 2022. As illustrative planning assumptions, building a center can take 12 to 18 months, while partnering with a supervised virtual provider can add capacity in weeks. The ATS 2023 guideline strongly recommends offering adults with stable chronic respiratory disease the choice of center-based rehab or telerehabilitation.

You discharge a patient after a COPD exacerbation, order pulmonary rehab, and it never happens. Motivation is part of it, and so is whether the referral was ever placed. But capacity is the part most often left out of the conversation, and the arithmetic is worse than most clinicians assume.

Pulmonary rehab is one of the few interventions in COPD that improves symptoms, exercise tolerance and quality of life, and starting it after a hospitalization is associated with better one-year survival. The supply of programs has never matched that evidence. This piece sets out how much capacity actually exists, what is known about whether it is shrinking, and the three realistic ways a hospital can add more.

How Much Pulmonary Rehab Capacity Actually Exists?

About 1,696 centers nationally, or one for every 6,030 Medicare beneficiaries with COPD. That is the most recent published national count, and the detail behind it matters for planning.

Using 2018 Medicare claims and 2020 facility data, Malla and colleagues identified 1,696 pulmonary rehabilitation centers nationally and published the analysis in 2023. Of 62.9 million Medicare beneficiaries, 10,376,949, or 16.5%, carried a COPD diagnosis. After excluding the outlying US islands and records with missing ZIP codes, their analytic population was 10,185,080, and against it they found one center for every 6,030 individuals with COPD. Those are the most recent published national figures, not a current census. Cardiac rehab runs close to 2,500 programs for a smaller eligible population.

Mean distance to the nearest center was 12.4 miles, with a standard deviation of 16.6, which sounds manageable until the number is split by geography.

Rural beneficiaries were 95% less likely than metropolitan ones to have a pulmonary rehab center within 10 miles. Fewer than one in nine has one within a reasonable drive, and for a patient on ambulatory oxygen, a 25-mile round trip two or three times a week for 12 weeks can be a serious barrier.

The certified subset is thinner still. Writing in CHEST Physician, Pourshahid and colleagues put it at roughly one certified program for every 43,000 people with COPD, with more than half of US counties holding no hospital-based outpatient program at all.

One caveat worth naming: 1,696 counts facilities, not slots. A program with two exercise stations and a single respiratory therapist counts the same as a twelve-station hospital program, so the ratio flatters the real picture rather than exaggerating it.

Is Supply Shrinking? What the VA Data Shows

The only system to have published a time series shows a steep decline. The Veterans Health Administration ran 125 center-based pulmonary rehab sites in 2018. By 2020 that had fallen to 37, and by 2022 to 33, a 73% loss from peak, with only 13 tele-PR sites operating. Moy and Nici reported the figures in AJRCCM in 2025 and suggested the loss "more than likely reflects similar trends throughout the United States." That is their concern rather than a measured national trend, and no equivalent national time series has been published.

The VA is not a proxy for national supply. It has salaried staff, integrated records and no fee-for-service margin pressure on the service line, so its numbers cannot show what happened to community programs. They are a warning sign rather than a measurement: the system least exposed to reimbursement economics still lost three quarters of its center-based programs and did not rebuild them, and its 13 tele-PR sites did not make up the difference.

What the Capacity Gap Costs Your Hospital

Only about 1.5% of Medicare beneficiaries hospitalized for COPD begin pulmonary rehab within 90 days of discharge, from a JAMA analysis of 197,376 patients. Fewer than 5% enroll at any point, per Pourshahid and colleagues in CHEST Physician. That is not a marginal underuse of a nice-to-have service. It is a near-total failure of a covered benefit with survival evidence behind it.

COPD is one of the six conditions in the Hospital Readmissions Reduction Program, so the patients your program cannot absorb are the same patients whose 30-day returns move the penalty. The mechanics of that exposure are covered in our guides to reducing COPD readmissions with technology and how CMS readmission penalties interact with rehab.

There is a second, quieter cost. A patient referred to a program 30 miles away is a patient referred into another system's follow-up, imaging and pulmonology clinic.

Why Adding Center-Based Capacity Rarely Solves It

Because unit economics do not support it. Medicare's bundled pulmonary rehab code, G0424, paid about $55.66 per session in 2021, the most recent published figure in the ATS analysis and indicative of the direction rather than today's exact rate, and the American Thoracic Society notes that outpatient PR reimbursement has declined significantly since January 2012, with hospitals under-reporting the true cost of delivery and reinforcing the underpayment. A one-hour supervised session with a credentialed clinician, floor space and equipment does not come in under that.

The Three Constraints That Cap Every Program

• Floor space. Exercise stations, monitoring equipment and clearance for oxygen-dependent patients compete with higher-margin outpatient services for the same square footage.
• Credentialed staff. Respiratory therapists and clinical exercise physiologists are the scarce input, and a program cannot flex staffing to demand the way an infusion suite can.
• Session throughput. Each patient occupies a station for up to 36 sessions across up to 36 weeks. Capacity is measured in patient-months, not appointments, so a full program stays full for a long time.

Expansion also carries a timeline nobody enjoys presenting: space planning, hiring into a shortage, physician supervision arrangements and Medicare conditions of participation. Twelve to eighteen months is a common planning assumption, not a measured average, and it can be optimistic.

Hypothetical Example: What One Center Can Absorb

Every number in this example is an assumption chosen for illustration, not data from any real program. It shows why theoretical capacity, actual use and completed patients are three different numbers.

• Weekly session slots. Six exercise stations, three one-hour classes a day, three days a week: 54 slots a week.
• Staffing constraint. If one respiratory therapist is available and supervises four patients at a time, each class caps at four, and usable capacity falls to 36 slots a week.
• Sessions per patient. A full course is 36 sessions, for example three a week for 12 weeks.
• Theoretical annual throughput. 36 slots a week over 50 weeks is 1,800 sessions, or 50 full courses a year.
• Utilization and completion. At 80% of slots filled, the program delivers 1,440 sessions. If the average patient attends 24 of 36 sessions, those serve about 60 patients, and only those who finish the course count as completers.

Set that against a hypothetical hospital discharging 400 eligible COPD patients a year, and even full theoretical capacity covers one patient in eight, before any referrals from clinics or other hospitals.

Three Ways to Add Pulmonary Rehab Capacity

There are only three, and they differ mainly in how fast capacity arrives and who keeps the patient.

Timings are illustrative planning assumptions based on published implementation experience, not measured averages. Network retention depends on the specific contracting and referral arrangement.

Guideline support for the virtual route is strong for a defined group. The American Thoracic Society's 2023 guideline makes a strong recommendation, on moderate-quality evidence, to offer adults with stable chronic respiratory disease the choice of center-based pulmonary rehab or telerehabilitation. The trials behind it used a range of remote models, so the operational questions still matter: who supervises, what is monitored, and whether the referral stays in network.

The build-versus-partner analysis is the same one cardiac programs have been running for several years, and the modeling steps carry across: our piece on cardiac rehab service line expansion walks through what to model before committing capital. The pulmonary case is simply starker, because the baseline supply is thinner and falling.

What to Require From an Outsourced Pulmonary Rehab Partner

Extending beyond your walls only works if the program on the other end is real rehab. Pourshahid and colleagues warn specifically that some commercial platforms lean on prerecorded content rather than live supervision. Seven things are worth making non-negotiable.

• Live supervision, not prerecorded content. Sessions delivered in real time by a named clinician. One-to-one delivery is a model choice rather than a coverage requirement, so ask whether sessions are individual or group and decide which your population needs.
• A named credential for whoever supervises. CMS requires physician-prescribed exercise delivered by appropriately qualified personnel; it does not name a specific profession. Ask which credential a vendor actually staffs to, and hold them to the answer. What a clinical exercise physiologist does sets out one such credential.
• Real-time vitals. Heart rate and oxygen saturation visible to the supervising clinician during exertion, not self-reported afterwards.
• Verifiable completion rates. Ask for the denominator. Completion in center-based programs runs low, and a vendor unwilling to define the measure is telling you something.
• Cardiac and pulmonary under one contract. Comorbid heart failure and COPD is common enough that splitting the two across vendors creates a triage problem. See cardiopulmonary rehabilitation for how the combined model works.
• Supervision and home coverage, separately. From January 1, 2026, CMS permanently allows the supervising physician's direct supervision to be met through real-time audio-video. Whether sessions delivered to a patient at home are covered is a separate rule, which currently runs through December 31, 2027. Our breakdown of the 2026 telehealth rules for cardiac and pulmonary rehab covers both.
• A referral workflow that survives discharge. An order in the EHR, not a phone number on an after-visit summary.

Carda Health delivers virtual cardiac and pulmonary rehabilitation with live one-to-one sessions supervised by a clinical exercise physiologist and real-time vitals monitoring from the patient's home. Carda patients attend 89% of their prescribed sessions on average (32 of 36), and Carda will supply the cohort and definition behind that figure on request. That is a program-level attendance measure. It is not comparable to the population-level initiation figures this article opened with, which count how many eligible patients ever start.

Referring When There Is No Program Nearby

Refer at discharge, and refer to whatever program can actually take the patient. Under 42 CFR 410.47, Medicare covers pulmonary rehab for moderate to very severe COPD, GOLD II to IV, on referral from the treating physician, and for confirmed or suspected COVID-19 with respiratory symptoms persisting four weeks or more. Coverage runs to 36 sessions over up to 36 weeks, extendable to 72 if medically necessary.

Do not hold the referral for the pulmonology follow-up. The post-discharge window is when the benefit is largest and when the patient is most likely to say yes. Eligibility, documentation and cost detail sit in our guide to Medicare coverage for pulmonary rehab.

If You Are the Patient

If you were told pulmonary rehab would help and then told there is no program near you, both things can be true. Ask your doctor directly whether a supervised at-home program is an option, because the referral usually has to come from them. In the meantime, ask your doctor whether it is safe for you to start exercising on your own. If they agree, pulmonary rehab exercises and practical steps for managing COPD at home are a reasonable holding pattern, not a replacement for a supervised program. Knowing which stage of COPD you have will also tell you whether you meet the coverage threshold.

The Bottom Line

Pulmonary rehab program capacity is a real constraint. One center per 6,030 Medicare COPD patients and half of US counties with no hospital-based program is not a gap that better patient education will close, and the one published time series, from the VA, points the wrong way.

Model the build if the volume and the space justify it. But do not let a capital timeline decide what happens to the patients you are discharging this month. As a planning assumption, extending the service beyond your walls through a supervised virtual program can add capacity in weeks and, depending on how the arrangement is structured, keep the referral in network. It also reaches rural patients and patients on oxygen for whom regular travel to a center is hard.

See how Carda Health partners with health systems

Frequently Asked Questions

How many pulmonary rehab programs are there in the United States?

About 1,696 pulmonary rehabilitation centers billed Medicare in the analysis by Malla and colleagues, roughly one for every 6,030 Medicare beneficiaries with COPD. The certified subset is far smaller, at approximately one certified program per 43,000 people with COPD.

Why is pulmonary rehab harder to access than cardiac rehab?

Supply. Cardiac rehab runs close to 2,500 programs nationally against roughly 1,696 pulmonary rehab centers, and the COPD population is larger. Reimbursement per session is also lower for pulmonary rehab, which discourages hospitals from opening or protecting programs.

Why do pulmonary rehab programs close?

National data on closures is limited, but economics is the usual pressure. Medicare paid about $55.66 per session for the bundled pulmonary rehab code in 2021, and the American Thoracic Society notes that outpatient reimbursement has declined significantly since 2012. Programs also compete for floor space and for scarce respiratory therapists and exercise physiologists. The clearest published example is the Veterans Health Administration, which lost 73% of its center-based sites between 2018 and 2022.

Can a hospital outsource its pulmonary rehab program?

Yes. A hospital can contract with a virtual pulmonary rehab provider and refer eligible patients into it, keeping the referral, the follow-up and the downstream care in network. As a planning assumption, that can add capacity in weeks rather than the 12 to 18 months often assumed for a center-based expansion.

How many pulmonary rehab sessions does Medicare cover?

Up to 36 one-hour sessions over up to 36 weeks, at most two per day, with up to 36 more if medically necessary. Our guide to Medicare coverage for pulmonary rehab covers eligibility, documentation and cost.

Did the 2026 Medicare rules change supervision for pulmonary rehab?

Yes. From January 1, 2026, CMS permanently allows direct supervision through real-time audio-video, so the supervising physician no longer has to be physically present. That is separate from home-based coverage: Medicare coverage of eligible sessions delivered to patients at home currently runs through December 31, 2027. Coverage of the sessions themselves continues to follow 42 CFR 410.47.

Is virtual pulmonary rehab as effective as a center-based program?

For adults with stable chronic respiratory disease, the evidence supports it. The American Thoracic Society's 2023 guideline strongly recommends offering the choice of center-based pulmonary rehab or telerehabilitation, based on moderate-quality evidence. The trials behind that recommendation used a range of remote models, so ask how each program supervises sessions and what it monitors. Programs report engagement on differing definitions, so check each one before comparing.

References

1. Malla G, et al. Access to Pulmonary Rehabilitation among Medicare Beneficiaries with Chronic Obstructive Pulmonary Disease. Annals of the American Thoracic Society, 2023.
2. Moy ML, Nici L. Alarming Loss of Pulmonary Rehabilitation Programs: Example from the U.S. Veterans Administration. American Journal of Respiratory and Critical Care Medicine, 2025.
3. Pourshahid O, Khan NA, Khan MK. Closing the Gap in Pulmonary Rehabilitation. CHEST Physician, November 2025.
4. Lindenauer PK, et al. Association Between Initiation of Pulmonary Rehabilitation After Hospitalization for COPD and 1-Year Survival Among Medicare Beneficiaries. JAMA, 2020.
5. American Thoracic Society. Pulmonary Rehabilitation in the United States: Updates on Covered Indications and Reimbursement.
6. Electronic Code of Federal Regulations. 42 CFR 410.47, Pulmonary Rehabilitation Program: Conditions for Coverage.
7. Centers for Medicare & Medicaid Services. Calendar Year 2026 Medicare Physician Fee Schedule Final Rule (CMS-1832-F).
8. Rochester CL, Alison JA, Carlin B, et al. Pulmonary Rehabilitation for Adults with Chronic Respiratory Disease: An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med. 2023;208(4):e7-e26.