Drug Channels reported that provider-administered drugs remain among the fastest-growing and least-managed costs for commercial plan sponsors. Drawing on data from the Pharmaceutical Strategies Group, the article noted that only 35% of commercial plan sponsors operate a site-of-care program for specialty pharmacy. That figure stands in sharp contrast to Medicare, which adopted site-neutral payments more than ten years ago. Even with clear evidence of savings, the analysis observed, many employers still pay hospital rates for infused therapies despite the availability of lower-cost settings.
The commentary points to a long-running efficiency gap between public and private payers. Medicare’s early adoption of site-neutral reimbursement illustrated that lower-acuity infusion settings can deliver identical therapies at far less cost. Commercial plans’ hesitation to follow appears tied to operational constraints, incomplete data integration between medical and pharmacy benefits, and hospital leverage in network contracting. The outcome: employers forgo potential savings. With only a third of plan sponsors enforcing site-of-care controls, the rest are effectively paying hospital markups on therapies that could just as easily be infused in physician offices or alternate sites. A costly pattern left unchecked.
In the near term, pressure is expected to mount from benefits consultants and stop-loss carriers urging employers to mirror Medicare’s pricing framework. As specialty spend migrates further into the medical benefit, site-of-care management could shift from optional to routine. PBMs and specialty networks capable of executing site-neutral contracts will likely meet strong demand from employers seeking measurable savings by 2026. For employer-side PBM benchmarking, see RxPBM.ai.
