Medical spend continues to rise, with one of the major cost-drivers being specialty medications and biologics for patients managing chronic conditions. Payers spend significant time and effort evaluating these drugs, negotiating pricing, and optimizing utilization. Yet one of the most powerful and often overlooked levers for controlling infusion-related drug spend is a combination of the site of care (SOC) and how the medication is sourced. 

Although these medications are often administered in a hospital, they can be more conveniently and efficiently provided in an outpatient facility or a patient’s home. The cost difference between these settings is massive, and research consistently shows that SOC plays a major role in total infusion cost.

For plans, this creates both a challenge and an opportunity. Optimizing infusion therapy SOC is an impactful strategy for controlling costs that should not be overlooked.

What the Data Shows: Site of Care Impacts Cost and Patient Satisfaction

Studies that analyze the cost differences between inpatient, outpatient, and home infusion therapy in the U.S. have concluded that when clinically appropriate, home and outpatient infusion are significantly less expensive than inpatient care. A 2023 literature review published in the National Home Infusion Association Journal reviewed six U.S. studies comparing home and outpatient infusion to inpatient infusion therapy. The review found that home infusion costs were a fraction of inpatient costs for the same therapies, especially for intravenous anti-infective treatments and other specialty infusions.

 

In one study, the average cost per day for home infusion was $225, compared to $586 for inpatient care. Another study showed the mean total cost savings for home infusion patients was over $80,000 when compared to inpatient costs. Across the literature review, home infusion consistently showed significant cost savings without compromising patient care. When taking into account that an overwhelming majority of patients prefer the convenience of at-home infusions, it truly becomes an opportunity that is beneficial to both the member and the plan sponsor.

Why Hospital Infusion Became the Default

Despite the evidence that supports at-home as the lowest SOC for infusions, hospital infusion is still the default setting for many therapies. While clinical necessity plays a role in some cases, there are several more contributing factors:

 

• Benefit design and utilization management may not address SOC.
• Hospitals are structurally positioned to retain a high volume of infusion patients.
• Plans may lack the data needed to identify when hospital-level care isn’t required.
• Some patients lack the proper education and training for at-home infusions.

Over time, the default to hospital infusions becomes increasingly expensive, as plans pay significantly more for the same medication and outcomes. This will become an even greater issue as specialty drug utilization and chronic conditions continue to rise, and plans that fail to optimize their infusion strategy will be hit hardest with uncontrolled costs.

What Smart Site of Care Optimization Means

Site of care optimization ensures that medications are delivered in the most appropriate setting based on clinical need, patient safety, and cost. Inpatient infusion is still critical for patients who need close monitoring or more complex infusion therapy, whereas home infusion is the optimal choice when it’s safe and clinically appropriate. 

 

Plans need the infrastructure to turn data into action, including:

 

• Visibility into infusion utilization and spend.
• Clinical oversight to assess medical necessity.
• Benefit design that supports alternative sites of care.
• Alignment between pharmacy and medical benefit management.

 

Without this infrastructure, even the strongest plans struggle to move beyond the hospital default for infusions.

How ELMCRx Supports Smarter Infusion Solutions

ELMCRx helps plan sponsors take action to better manage spend, including infusion therapies. Many plans lack a clear understanding of which infusion drugs are driving costs or how often hospital settings are used when they may not be necessary. ELMCRx helps surface those patterns, provides clinical and utilization management support, and ultimately offers a solution to provide patients with the most convenient, clinically appropriate, and cost effective site of care possible.

A Smarter Way to Manage Infusion Costs

As chronic conditions rise and specialty drugs become more common, infusion volumes and costs will only increase. Where these therapies happen plays a critical role in the total cost of care. Plans that take a more strategic and data-backed approach to infusion site of care will better manage rising costs while ensuring access, safety, and a positive patient experience. 

Contact us to learn how ELMCRx supports our partners in lowering this significant cost driver with our innovative, proactive solutions.