Cost differentials are driving site of care policy scrutiny

As margin pressure increases, payers typically lean more heavily on established utilization management tools to reduce unwarranted cost variation. And when they turn to utilization controls, they start with the categories where there is clear cost variation and existing policy infrastructure. Infusion is near the top of that list. The cost differential between hospital outpatient departments (HOPD) and alternate sites of care (SOC) has long been well documented, but new research provides payers with fresh justification to accelerate action.

A recent large-scale analysis published in the Journal of Managed Care & Specialty Pharmacy compared more than 52,000 infusions and found no clinically significant differences in short-term safety outcomes in cases where the hospital outpatient setting was not medically necessary, while outpatient costs were nearly forty-two percent higher in the hospital environment¹. For payers under pressure, this kind of data is not academic. It is a roadmap. It gives them documented rationale to expand site-of-care policies, increase documentation requirements, and redirect patients more consistently toward lower cost settings.

A recent large-scale analysis published in the Journal of Managed Care & Specialty Pharmacy compared more than 52,000 infusions and found no clinically significant differences in short-term safety outcomes in cases where the hospital outpatient setting was not medically necessary, while outpatient costs were nearly forty-two percent higher in the hospital environment¹. For payers under pressure, this kind of data is not academic. It is a roadmap. It gives them documented rationale to expand site-of-care policies, increase documentation requirements, and redirect patients more consistently toward lower cost settings.

This does not mean HOPDs are unnecessary. HOPDs remain essential for higher-acuity patients, patients with elevated reaction risk, patients initiating or changing regimens, and patients who cannot access alternate sites of care.¹ But it does reinforce a reality health systems see on the ground: payers are increasingly prepared to push volume toward lower-cost settings when medical necessity is not clearly demonstrated.

While the exact pace will differ by payer, contract, and geography, the operational direction for providers is consistent: more site-of-care restrictions and more administrative and documentation requirements when HOPD use is not clearly supported.

In our view, the implications of this study and the financial headwinds payers face are clear: SOC program usage will accelerate, and restrictions will expand into more therapeutic areas, including historically HOPD-only therapies like oncology. Health systems that proactively build diversified infusion portfolios, supported by clear referral routing logic, clinical criteria, and consistent documentation, will be best positioned to maintain successful and margin-positive infusion service lines.

What health systems should do now
Fundamentally, health systems still have the ability to determine whether these payer controls disrupt their operations, or simply redirect care within a thoughtful, well-designed, multi-site infusion strategy. The difference between those two outcomes will depend on how quickly systems act, how seriously they take the coming shift, and how effectively they prepare for a market where site-of-care strategy management is no longer optional, but essential to long term performance.

As payer pressure accelerates, health systems that act early will be the ones that maintain control of infusion access, continuity, and volume. Three priorities matter most:

1. Protect appropriate HOPD volumes by standardizing clinical criteria and documentation

Many patients legitimately require hospital-based infusion, but payers increasingly expect explicit justification. The challenge isn’t clinical nuance; it’s presenting that nuance in payer-recognized language. Clear pathways that distinguish therapy initiation from maintenance, escalation criteria tied to monitoring or reaction risk, and standardized “medical necessity” language all help ensure that appropriate HOPD care is approved the first time.

2. Develop alternate site strategies so patients stay inside the system when HOPD denials occur
The biggest financial risk isn’t the HOPD denial alone, it’s the risk that the patient moves to an external site and the health system loses access to providing that patient's future downstream care. Establishing alternate sites within the health system helps maintain patient relationships and enables the health system to be the first option for future care needs.

3. Treat site-of-care policy management as a core operating requirement
Payer SOC rules are becoming a routine part of infusion management. To keep patients in the system, health systems need consistent workflows that make every SOC decision predictable and ensure each referral is managed consistently. A diversified SOC strategy only works when it feels seamless: coordinated prior authorization management, shared visibility of capacity across sites, unified patient scheduling, and aligned economic models. When those elements are connected, a site shift becomes a guided care transition rather than a loss of care continuity.

Questions to assess your risk and readiness:

• Where is my system most exposed to leakage if payer site-of-care direction accelerates? Who are my biggest payers and what SOC actions are most likely?
• How competitive is my alternate infusion site market? Do payers have options to quickly route volume out of my system to free-standing or provider-owned sites?
• If my system executed an alternate infusion site strategy, does it have the operational infrastructure to effectively set up and scale those sites quickly
• What gaps may exist in establishing a referral management strategy to navigate payer SOC program restrictions?

For more on how Accelerate Pharmacy Solutions helps health systems protect and grow infusion programs, read NHIA’s Exhibitor Spotlight.

This article is for informational purposes only, and does not constitute medical, legal, or other professional advice. Readers should verify all details before taking action and are solely responsible for ensuring that all provided services comply with applicable laws, regulations, rules, and requirements. 

References

^1. Cullen D, Gordon AS, Adkins Svoboda S, Alvarez M, Cobb R. Infusion therapy patient outcomes are similar at reduced costs in alternative sites of care compared with hospital outpatient departments: A matched cohort analysis of infusion therapy across multiple chronic conditions. Journal of Managed Care and Specialty Pharmacy. 2026;32(2):1-11. Accessed February 17, 2026. https://www.jmcp.org/doi/10.18553/jmcp.2025.25264

^2. Franck T. Health insurers tumble after Trump proposes keeping Medicare rates flat. CNBC. January 26, 2026. Accessed February 17, 2026. https://www.cnbc.com/2026/01/26/health-insurers-tumble-after-trump-proposes-keeping-medicare-rates-flat.html

^3. Centers for Medicare & Medicaid Services. CMS proposes 2027 Medicare Advantage and Part D payment policies to improve payment accuracy and sustainability. Press release. January 26, 2026. Accessed February 17, 2026. https://www.cms.gov/newsroom/press-releases/cms-proposes-2027-medicare-advantage-part-d-payment-policies-improve-payment-accuracy-sustainability

^4. McCrear S. CMS Proposes Nearly Flat 2027 Medicare Advantage Payment Rates. The American Journal of Managed Care. January 27, 2026. Accessed February 17, 2026. https://www.ajmc.com/view/cms-proposes-nearly-flat-2027-medicare-advantage-payment-rates

^5. Mintz. Medicare Advantage Under the Microscope: Enforcement Priorities and Legal Battles. January 13, 2026. Accessed March 10, 2026. https://www.mintz.com/insights-center/viewpoints/2406/2026-01-13-medicare-advantage-under-microscope-enforcement

^6. Kaiser Family Foundation (KFF). Recent Trends in GLP-1 Use and Spending in Medicare. January 30, 2026. Accessed February 17, 2026. https://www.kff.org/medicare/recent-trends-in-glp-1-use-and-spending-in-medicare/