Beyond the Walls, in Brief

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What this report will tell you (and why you should care)

If you work anywhere near care delivery, payment policy, or health operations, or you are a leader in healthcare or health tech, 2026 is not a typical year for hospitals. Four structural forces (regulatory, statutory, commercial, and capital) are moving in the same direction for the first time in two decades. The result: billions in hospital‑based revenue are being redirected toward offices, ASCs, and the home.

This report breaks down what changed, why it’s happening now, and what it means for clinicians, operators, and policy pros who need to stay ahead of the slope.

Executive Summary | The 2026 Site‑of‑Service Reset

1. Hospital spending is the biggest and fastest‑growing line in U.S. healthcare.

Hospitals captured $1.6T in 2024 and drove 40% of national spending growth. Prices have outpaced inflation for two straight years.

2. Inpatient volume keeps shrinking while outpatient keeps rising.

Between 2000 and 2023, inpatient admissions dropped by nearly 19%, while outpatient visits surged by 31%.

3. Four forces are converging in 2026

• Regulatory: IPO list elimination, ASC list expansion, OPPS site‑neutral expansion, PFS indirect‑PE redistribution.

• Statutory: Unique NPI requirement for off‑campus HOPDs, Hospital‑at‑Home extension to 2030.

• Commercial: Employers and MA plans steering aggressively to lower‑cost sites.

• Capital: Nearly $40B in PE investment into ASCs across 2024–2025.
  Together, these forces are structural, not cyclical.

4. CMS moved more in one rulemaking cycle than in the last decade.

• 285 procedures removed from the IPO list in 2026.

• 547 procedures added to the ASC list.

• Grandfathered HOPDs now paid 40% of OPPS for drug administration.

• Facility‑based cardiology projected to see –7% revenue change from PFS redistribution.

5. Home is now a (nearly) permanent, reimbursed site of care.

Hospital‑at‑Home is extended through 2030, with outcomes showing 38% lower cost and 44% lower readmissions. Virtual supervision is permanent. RPM is standard. The home is now part of hospitals’ infrastructure.

6. By 2030, the slope, not the direction, is what’s uncertain.

The optimistic scenario? Maybe it shifts $200B+ in outpatient spend to ASCs, offices, and home. The pessimistic scenario slows federal savings but doesn’t stop commercial migration. The baseline: steady erosion of hospital pricing power and a consolidation wave.

So here’s what you now know

The shift away from hospital‑based care is at least partially the result of a structural realignment of incentives, capital, and clinical capability. That means:

• Clinicians should position around outpatient leverage: ASC partnerships, portable case mix, or APM‑aligned work.

• Healthcare leaders should track the boring‑but‑foundational infrastructure changes (unique NPIs, site‑neutral scoring, state facility‑fee bans) that set up the next round of reform.

• Operators and health tech should build for distributed care—ASC‑grade systems, home‑based diagnostics, and coordination across fragmented sites.

The takeaway:
Care delivery finally moving to the settings where patients prefer to be, and where the system can afford to send them.

Use this report as your briefing for the next phase of the shift. The levers are already pulled. The question now is how you position yourself and how it might impact you and your work.