A health-system executive view of how novel, high-cost therapies reshape working capital, payer onboarding, specialty staffing, safety-monitoring logistics, formulary governance, site-of-care strategy, and the infrastructure needed to scale access without exposing the organization to unmanaged financial or operational risk.
Audience: Hospital Administrators
Countries: 3
Completion Rate: 80%
SGID: 8951420
-Hero findings
– Quick Read — Key Findings
For hospital executives, the launch of a high-cost therapy is not a single formulary decision. It is a chain of capital, contracting, pharmacy, staffing, diagnostics, scheduling, revenue-cycle, and site-of-care decisions that must hold together before the first patient is treated.
That complexity is increasingly visible in policy and practice: CMS’s Cell and Gene Therapy Access Model is testing outcomes-based agreements for sickle cell gene therapies and requires participating Medicaid programs to make operational and reimbursement changes that support access, and ASHP policy places supply chain, operational oversight, formulary governance, financial risk, and payment models inside the health-system medication-use process. The MDForLives survey asks administrators and executives where this operating model strains first, and the strongest signals are not concentrated in one department, they span upfront payer guarantees, reimbursement economics, specialized nursing, diagnostic scheduling, executive governance, centralization of complex care, and specialized pharmacy infrastructure.
50.0% say their primary financial strategy is strict upfront payer prior authorization and guaranteed coverage terms before drug acquisition.
White or clear bagging is chosen by 25.0%, traditional buy-and-bill supported by hospital reserves by 18.8%, and manufacturer risk-sharing by only 6.3%, so the dominant move is to reduce uncertainty before cash leaves the system. The open-ended comments sharpen it: executives fear buying million-dollar therapies upfront while reimbursement stays unsettled, delayed, or exposed to denials, which turns authorization from an access workflow into a treasury control.
37.5% identify low reimbursement rates or ASP markups that fail to cover pharmacy handling, compounding, and administrative overhead as their most severe onboarding friction.
Prior authorization cycles and coverage criteria narrower than the label are each 25.0%, and site-of-care restrictions 12.5%, so the burden is not one bottleneck but a sequence of verification, eligibility, authorization, reimbursement, and site rules. Policy is targeting the same seam: CMS’s 2024 interoperability and prior authorization rule began operational requirements in 2026, and an April 2026 proposal would extend electronic prior authorization to drugs, showing how actively the drug-authorization workflow is being standardized.
56.3% identify shortages of specialized nursing staff qualified for complex monitoring and administration as the single greatest throughput constraint.
Diagnostic and laboratory capacity follows at 18.8%, with infusion chair availability and specialized pharmacy capacity each at 12.5%, which reframes expansion planning: adding physical space without the clinicians to run the service may not add usable capacity. The future-investment question echoes it, 25.0% prioritize recruiting and retaining specialty nurses, pharmacists, and advanced-practice clinicians, so complex-therapy capacity is partly a labor-market problem and partly a workflow-design problem.
37.5% reserve dedicated fast-track diagnostic or imaging slots specifically for specialty-therapy patients.
37.5% use a centralized executive panel for formulary governance, while 50.0% prioritize a main-campus Center of Excellence for future site-of-care growth.
A dedicated Precision Medicine and Novel Therapeutics committee sits close behind centralized executive governance at 31.3%, with service-line governance at 18.8% and ad-hoc planning 12.5%; on site of care, hospital-owned ambulatory infusion and community partnerships are each 18.8% and home infusion 12.5%. Together the two questions show a preference for concentration where complexity is highest: a centralized body can weigh enterprise risk, and a Center of Excellence can pool pharmacy, staffing, diagnostics, safety pathways, and financial expertise in one model.
37.5% rank specialized pharmacy, cold-chain, and point-of-care manufacturing infrastructure as the most critical investment for scaling novel therapeutics safely.
Automated EHR decision support and revenue-cycle tools for prior authorization follow at 31.3%, specialized clinical talent at 25.0%, and upgraded diagnostics at 6.3%, so the priorities span product handling, digital authorization, workforce, and diagnostic support. The open-ended comments repeat the same themes, reimbursement uncertainty, denials, upfront cash exposure, staffing and scheduling, contract complexity, and site-of-care or DRG mismatches, with a smaller set citing budget limits, prescribing discipline, and life-cycle contracts.
The strongest signals sit at the interfaces between departments: finance wants coverage certainty before acquisition, revenue-cycle teams face prior authorization, narrow criteria, reimbursement gaps, and site-of-care rules, clinical operations are constrained by specialized nurses and tightly timed diagnostics, pharmacy needs infrastructure for high-cost handling, and leadership must decide who owns formulary risk and where therapies are delivered.
The survey also shows why a narrow fix is not enough: a new EHR workflow cannot solve inadequate reimbursement, more infusion chairs cannot solve a nursing shortage, and a Center of Excellence cannot scale if the payer model still exposes the hospital to unrecoverable acquisition cost. The more complex the therapy, the more readiness depends on synchronizing financial, clinical, pharmacy, diagnostic, and operational capacity before demand arrives.
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