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.

Two Incentive Layers, And Why You May Feel Stuck

It’s easy to think this as a clinician: If you do good work, the system will reward you.

But healthcare isn’t one system. It’s two incentive layers running on top of each other:

• Personal incentives (you): patient outcomes, professional reputation, work-life balance, clinical craft, doing the right thing.

• Organizational incentives (your employer): revenue, efficiency metrics, market share, payer leverage, throughput, risk, and optics.

If you don’t separate these two layers, you end up in constant confusion:

“Why is leadership pushing this?” “Why doesn’t this change?” “Why do I feel like I’m compromising?”

The cause of confusion? An incentive mismatch.

Stop trying to “find a better job” before you learn to read the incentive layer you’re standing on.

Because incentives shape what gets measured, funded, staffed, and rewarded—and that shapes your options.

Why this matters in any setting

When you can name the incentive conflict clearly:

• You stop internalizing it as personal failure (“I’m not doing enough”)

• You reduce moral injury (“I’m trapped in a system that rewards the wrong thing”)

• You gain leverage (“I know what language decision-makers respond to”)

Or said differently:

You stop asking “why don’t they just do the right thing?” and start asking:

“What would make the right thing the easy thing?”

The real career unlock: learn which lever you’re holding

Here are a few examples of how incentives quietly steer your day-to-day—and your career ceiling:

• Hospital-based practice

  If the system earns more from facility-based billing, there can be subtle pressure to keep services in-house. Understanding this helps you advocate for the safest, most appropriate site of care and avoid getting pulled into “keep the volume” politics.

• Primary care

  If compensation is panel size and RVUs, prevention and coordination get squeezed. Clinicians who understand this often build a niche: complex care management, value-based programs, team-based workflows, quality leadership.

• Anywhere you’re asked to do “more” with no resources

  “We want better outcomes and happier staff” paired with no staffing change is an incentive mismatch. Naming it is how you ask for the missing input: time, training, tools, staffing.

A simple framework to save and reference later 👇️ 

Ask these 3 questions about any role you’re in or considering:

1. What gets paid for?

2. What gets measured and reported?

3. Who benefits if we do more of X and less of Y? 

If you can answer those, you can predict your future stress points and your future opportunities.

Write 2 short lists:

A) Personal Incentives (Top 5)

What you actually optimize for (even if you haven’t been allowed to say it out loud): outcomes, autonomy, schedule, mastery, relationships, energy, learning, leadership, etc.

B) Organizational Incentives (Top 5)

What your employer optimizes for: volume, RVUs, payer mix, downstream capture, length of stay, star ratings, HEDIS, readmissions, margin, referrals, etc.

Then answer:

Where do these overlap? Where do they clash?

That clash is your burnout risk.

That overlap is your career leverage.

How this helps your career (and makes you feel less powerless)

When you learn incentives, you can:

Make better career decisions: Evaluate jobs by the real drivers, not the brochure.

Negotiate smarter: Ask for what changes outcomes/workload: support staff, visit length, protected time, caseload caps, documentation support, training budget.

Influence more effectively: Frame proposals in access, retention, quality, cost avoidance, risk reduction, patient experience.

This is the difference between being “right” and being effective.

*Disclaimer: All opinions and ideas expressed in this article are solely mine and none represent a recommendation or should be viewed as advisement of any kind to anyone to do anything.*