Medicare and commercial payers are steering infusion toward lower-cost settings, including patients’ homes, oncology and pharmacy leaders at five health systems told Becker’s.
But a lower-cost site is not a lower-effort one. To deliver infusion safely at home, health systems need oncology-trained nurses, sterile compounding, around-the-clock pharmacy support, caregiver education and a plan to escalate care if a patient reacts to treatment, leaders said.
“The biggest [coverage] gap is reimbursement that adequately covers nursing, pharmacy, monitoring and care coordination, not just the medication and its administration,” Blake Herring, MSN, RN, associate chief of service lines for cancer services at UVA Comprehensive Cancer Center, part of Charlottesville, Va.-based UVA Health, told Becker’s.
Where — and why — infusion is moving
At Sacramento, Calif.-based UC Davis Health, UC San Diego Health and UVA Health, payer policies that require lower-cost sites of care are moving more infusion out of hospital outpatient departments, leaders said.
UC Davis Health manages infusion through a systemwide steering committee spanning outpatient departments, ambulatory infusion centers and home infusion. For many drugs, the hospital outpatient department is no longer the default setting, Kofi Andoh, PharmD, assistant chief pharmacy officer at UC Davis Health, told Becker’s.
UC San Diego Health operates four hospital-based infusion centers, two provider-based centers and a pharmacy infusion service that treats patients at home and in an on-site infusion suite, according to Ashley Dalton, PharmD, associate chief pharmacy officer. She said limited chair capacity drove much of that growth.
UVA Health offers infusion at its academic medical center and community-based cancer centers, but only sparingly at home, Mr. Herring said. The system is building more outpatient infusion capacity in the communities it serves, a push driven by access and clinical appropriateness, he said.
Banner MD Anderson Cancer Center, part of Phoenix-based Banner Health, offers infusion in inpatient units, outpatient clinics, ambulatory infusion suites and patients’ homes across its Arizona and Colorado sites, according to Cory Jones, systemwide assistant vice president of oncology services. He said mounting pressure is changing site of care, but clinical appropriateness and patient needs guide the system’s decisions.
Boston-based Tufts Medical Center, part of Burlington, Mass.-based Tufts Medicine, is not overhauling its approach, said Kathleen Coughlin, a hematology and oncology nurse practitioner and clinical nursing director of the cancer center. The cancer center weighs home infusion case by case based on safety, clinical complexity and what patients want.
How health systems decide where infusion belongs
UC Davis Health started home oncology infusion with nonhazardous cancer drugs such as pembrolizumab and daratumumab, Dr. Andoh said. The system plans to expand to every chemotherapy agent on the National Home Infusion Association’s drug list, while drugs with complex or acute toxicities will stay in its hospital-based centers.
Mr. Herring said UVA Health gives few oncology-related infusions at home today, with supportive care and lower-risk therapies the likeliest candidates to add.
“I would be cautious about moving chemotherapy, immunotherapy and other complex treatments outside a clinical setting where immediate assessment and intervention may be necessary,” he said.
UC San Diego Health is similarly selective about oncology infusion at home.
“We do not actively seek to transition oncology patients to the home; those decisions are generally driven by patient preference or payer site-of-care requirements,” Dr. Dalton told Becker’s.
When payers redirect oncology patients to UC San Diego Health’s pharmacy infusion service, most are treated in its on-site chairs rather than at home. Patients receive select immunotherapies and supportive care or maintenance therapies they have already received safely in a higher-acuity setting. Across the service, patients choose the chairs over home more often, she said.
Amanda Dean Martin, DNP, COO of oncology services at Banner MD Anderson, said the safest decision rests on the patient’s overall health, prior reactions and caregiver support at home, along with a drug’s potential reaction risk and how well it travels. Banner is more careful with hematologic cancer drugs that carry a higher risk of cytokine release syndrome, she said.
“It gets even more complicated with home infusion because every home is different,” Dr. Dean Martin told Becker’s.
At Tufts, specialty infusions that need closer monitoring or immediate access to intervention stay in a hospital-based or ambulatory setting, Ms. Coughlin said. Many patients also prefer to stay on-site with their established care team.
“Our goal is not simply to move infusions out of the hospital, but to provide patients with safe, appropriate options that best meet their individual needs,” Ms. Coughlin told Becker’s.
What safe home infusion requires
“Delivering infusion safely in the home requires much more than simply relocating the treatment,” Ms. Coughlin said.
Before a home infusion program treats its first patient, it needs pharmacy and home health licenses, accreditation, Medicare enrollment as a durable medical equipment supplier, liability protections and payer contracts, Dr. Andoh said. It also needs administrative staff for intake, billing, revenue cycle and quality.
For the most complex drugs, Dr. Dean Martin said programs need chemotherapy-certified oncology nurses who can manage reactions in the home, a defined escalation pathway to the nearest hospital and pharmacists as involved as they would be in a hospital outpatient department. Caregivers also carry more of the load at home, with fewer opportunities for education.
“It’s really all on one nurse in that space,” she said.
Geography narrows eligibility further. Patients who live in homes without reliable water or electricity, or in areas nurses or ambulances cannot reach quickly, may be ineligible for home treatment, Dr. Dean Martin said. Banner MD Anderson’s home care team builds relationships with local fire departments and private ambulance companies in each service area to close that gap.
Mr. Jones said that depends on tight integration among Banner’s acute, ambulatory and home infusion teams.
Dr. Dalton said nurses also need training to recognize unsafe conditions in a home.
The home infusion reimbursement gap
Nationally, home infusion is paid far less than hospital-based infusion, Dr. Andoh said, largely because hospital rates cover facility fees, overhead and administrative costs, and hospital drug contracts are often tied to a percentage of billed charges. The bigger problem for home programs is coverage, which is most fragmented in traditional Medicare and state Medicaid programs, he said.
Medicare’s Part B home infusion therapy benefit, created under the 21st Century Cures Act, covers a narrow set of pump-administered drugs, roughly 30 to 40 by Dr. Andoh’s estimate, and pays for professional services only on days a clinician is in the home.
Drugs that fall under Part D come without matching coverage for the pharmacy services, supplies and nursing needed to administer them, Dr. Dalton said.
“Home infusion programs typically must revert to split billing to cover all associated care for a patient,” Dr. Andoh said. “This can look like billing [the] drug through the pharmacy benefit, billing supplies [and durable medical equipment] through the medical benefit and partnering with external nursing [or] home health agencies to provide nursing.”
Commercial plans generally pay separately for the drug, a per diem covering pharmacy services and supplies, and nursing visits, according to Dr. Dalton and Dr. Andoh. Medicare Advantage can bridge some of the gaps between medical and pharmacy benefits, though both said that varies by plan.
The biggest gap, Dr. Dalton said, is the clinical work between nursing visits: compounding, monitoring, patient education, delivery and on-call clinical support.
“Moving treatment into the home is sustainable only when reimbursement recognizes that full scope of care,” she said.
Banner MD Anderson does not start with reimbursement when deciding where patients are treated, Mr. Jones said. Payment does differ by setting, he acknowledged, but the bigger gap is that payer policies do not reflect what it actually costs to deliver care in each one.
“It’s not just about the drug, right? It’s about the whole infrastructure as well,” Mr. Jones told Becker’s.
When reimbursement for home infusion falls short, uninsured and underinsured patients feel it most, widening existing gaps in care, Dr. Dean Martin said.
How 340B cuts and site neutrality may reshape infusion care
Site-neutral payment changes and 340B reimbursement cuts are putting financial pressure on hospital-based infusion, pushing leaders to rethink which therapies belong in which setting.
For 2026, CMS extended site-neutral rates to drug administration services at hospital outpatient departments located off the main campus, including previously exempt sites, aligning Medicare payment for infusion at those sites with physician office rates.
CMS’ finalized 2027 outpatient payment rule includes a steeper cut to 340B drug reimbursement. Beginning Jan. 1, hospitals will be paid 28% below the average sales price for 340B-acquired drugs, compared with the 6% above sales price they are paid today. Children’s hospitals, rural sole community hospitals and certain freestanding cancer hospitals are exempt.
Leaders at UC Davis Health, UVA Health, UC San Diego Health and Tufts, who spoke with Becker’s before the rule was finalized, said the 340B and site-neutral changes were already factoring into their infusion planning.
At UC Davis Health, the changes prompted a review of contribution margin across every infusion site to decide which therapies are best given where, Dr. Andoh said. The system also created a centralized infusion authorization team to serve as one entry point for infusion referrals. That team routes each patient to a site based on drug acquisition cost, payer reimbursement, location, operational complexity and clinical needs.
Dr. Dean Martin said paying all sites the same overlooks what hospital outpatient departments provide, including certification from The Joint Commission, state and federal oversight and highly certified nurses treating the sickest and most complex patients. Community infusion centers do not face the same regulatory, staffing or patient safety requirements, she said. She described 340B savings as “a lifeline” that lets hospitals care for more complex and underserved patients, and said broad site-neutral payment would limit access for the most vulnerable.
“My concern is that reimbursement reductions do not necessarily reflect the cost of caring for complex oncology patients, and changes to 340B could limit our ability to reinvest in programs and services that support comprehensive cancer care,” Mr. Herring said.
Dr. Dalton said the 340B reductions would squeeze resources as infusion demand grows and make long-term planning harder.
“Payment changes influence those decisions, but they do not change the clinical requirements of treatment,” she said.
What home infusion needs from payers and policymakers
Leaders said home infusion will not scale without changes to how payers cover it, starting with Medicare.
“A comprehensive Medicare benefit would be a great start,” Dr. Andoh said. “If CMS replicated the comprehensive home infusion benefit offered amongst commercial payors, we would be well positioned for home infusion to work at an exponentially larger scale.”
He urged policymakers to back the bipartisan Preserving Patient Access to Home Infusion Act, introduced in the House and Senate in March 2025 and supported by the National Home Infusion Association. The bill would pay for professional services every day a drug is administered, not only on days a nurse visits, with days that have no visit paid at half the rate. It would also define the pharmacy services Medicare covers.
Dr. Dalton said payers could help by simplifying authorization and coordinating coverage of the drug with coverage of the services needed to give it.
“A site-of-care requirement should come with a workable pathway to receive treatment, including access to qualified providers and appropriate clinical exceptions,” she said.
Mr. Herring called for payers and health systems to build models around total cost of care, patient outcomes and experience “rather than focusing solely on reducing the cost of an infusion encounter.”
“Ultimately, expanding home infusion should be about increasing access and providing patients with more choices, not creating barriers to hospital-based care for those who need or prefer it,” Ms. Coughlin said.
For Mr. Jones, the message for payers and policymakers is that a lower-cost site still needs investment behind it. Home infusion may be seen as the cheaper option, he said, but it cannot work without the infrastructure to support it.
