Changing Site-of-Care Dynamics and the Growth of Self-Administered Therapies
Patients have expanding options for where to receive and take their medications. Both payers and manufacturers can capitalize on these options to improve patient access, adherence, and outcomes.
Within many therapeutic areas (TAs), medications that were previously covered by the medical benefit are now covered by the pharmacy benefit. To accommodate the new benefit designs, payer preferences regarding sites of care and routes of administration are also shifting. These changes have allowed payers to better control specialty drug spending.
Traditionally, patients received infusions at physician offices, hospital outpatient departments (HOPDs), and freestanding infusion centers. In recent years, many patients have also begun receiving infusions at home, with the assistance of nurses or medical professionals employed by home healthcare agencies. Now, with many infusion therapies being reformulated as subcutaneous therapies, self-administration is providing another attractive option for patients.
In light of these trends, our Biologics & Injectables Index team conducted research on site-of-care preferences to determine how payers and providers expect these dynamics to change in 2025.
Shifts in Infusion Center, HOPD, and At-Home Utilization
As of Q2 2024, payers reported that infusion centers and physicians’ offices, followed by HOPDs, were the most utilized sites of care for members’ infusion therapies. Only 17% of commercially covered members received infusion therapies via self-administration, followed closely by 16% of members who used in-home administration services.
However, payers believe a dramatic shift in site-of-care utilization is coming. By 2025, payers expect that most of their patients will receive infusion treatments either at freestanding infusion centers (48% of commercial lives) or at home, rather than at inpatient settings. By 2025, they believe that self-administration will become a top site-of-care setting, replacing HOPD administration, which they expect will decrease from 24% of commercial lives to 1%. Payers cited increased cost effectiveness for members and a simplified scheduling process as the top two top drivers of these shifts.
Surveyed providers, on the other hand, disagree that infusion site-of-care dynamics will change quite so dramatically. Providers agree that the utilization of freestanding infusion centers and self-administered therapies will increase, although to a lesser degree than payers, while the use of in-home administrative services will significantly decrease. However, they do not believe that the HOPD site of care will be eradicated; surveyed HCPs anticipate that 18% of patients will still receive transfusions at HOPDs.
Reimbursement Impact of Non-Preferred Sites of Care
MMIT’s research also indicates that payers exhibit marked site-of-care preferences depending on the therapeutic area. Within rheumatoid arthritis, hemophilia, and immunodeficiency TAs, payers prefer in-home administration. However, payers prefer infusion centers as the site of care for oncology patients and those with ocular disease and HIV.
These site-of-care shifts clearly have implications for reimbursement and acquisition. Overall, payers identify buy-and-bill as the most common acquisition method for non-oncology specialty therapies administered in-office, at infusion centers, or at HOPDs. For self-administered and in-home administered therapies, the drug’s average wholesale price serves as the benchmark for reimbursement calculations.
In MMIT’s research, nearly two-thirds (68%) of surveyed physicians say payers will reimburse at a higher rate when their preferred sites of care are utilized. And in many cases, payers refuse to cover treatment that is administered at a non-preferred site of care. As several physicians noted, denied claims often cite reasons like “office-based infusions are not covered by the patient’s insurance,” or “administration of medication must occur at preferred infusion center.”
Benefits of At-Home Administration
Overall, both HCPs and payers agree that administrative route changes can be beneficial for patients. Most surveyed physicians say patients are likely to choose self-administered therapies for greater convenience (88%), reduced cost (75%) and greater patient satisfaction (63%). Another benefit of home utilization is increased access to medications. Alternate formulations of infusion therapies may improve access because they can be self-administered and may not need to be refrigerated.
Home administration of injectable therapies may also improve medication adherence, just as the shift from an injectable to an oral medication often does. For example, in a study on MS patients, switching the route of administration from injectable to oral resulted in better patient adherence, quality of life, and patient satisfaction with treatment. For some indications, such as schizophrenia and Alzheimer’s, medication adherence is an especially critical issue.
In our research, multiple payers noted the need for providers to “assist with site-of-care information, particularly for limited distribution/limited site of service medications.” Educating providers about the safety and efficacy of alternative formulations will help drive awareness of these options, ultimately increasing prescriptions.
Leveraging Site-of-Care Trends to Improve Utilization
Both payers and manufacturers should pivot their strategies to adapt to these shifts in how care is received and reimbursed. First, payers can provide coverage for these emerging products at both patient- and provider-preferred sites of care. Payers will benefit from their members’ increased medication access and adherence. Payers should also work with HCPs to educate them on the impact of alternative sites of care on patient outcomes.
To capitalize on these site-of-care shifts, manufacturers should:
- Prioritize the development of products that can be routinely and safely administered outside of an outpatient setting. This strategy is likely to be financially beneficial, as payers are more likely to cover these products and offer a higher rate of reimbursement.
- Incorporate patient-reported outcomes and qualitative research on payer preferences to determine the preferred route of administration for both patients and payers. This research can help guide a manufacturer’s development and market access strategy.
- Capitalize on their development of pharmacy benefit formulations by offering rebates during the payer contracting process. Smart payer negotiation can give manufacturers an edge over competitors who are not using payers’ preferred sites.
In addition, manufacturers should also take steps to ensure patients have easy access to their medications at their preferred site of care. As care options expand to include more at-home and infusion center treatments, patients will benefit from improved access, adherence, and convenience. Manufacturers and payers can refine their strategies to align with these new sites of care, creating mutually beneficial outcomes for both patients and providers.
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