Sites Are Walking Away: Why Payment Experience is the New Competitive Advantage
Applied Clinical Trials Online
Payment experience—including how, when, and with what level of transparency sites are compensated—is rapidly emerging as a defining factor in the success of clinical trials. Once dismissed as a simple operational nuisance, payments are now recognized as a critical component for shaping site relationships and study outcomes.
For years, sites had limited leverage in the matter. Sponsors and clinical research organizations (CROs) dictated terms, and sites were required to absorb this administrative burden as a cost of their involvement. Now, as competition for experienced sites intensifies and operational complexities continues to grow, that dynamic is shifting, giving sites increasingly more agency over who they work with, and how they get treated.
This critical paradigm shift is forcing sponsors and CROs to rethink their long-standing assumptions. Payments are no longer just an administrative function. Now, they have become a front-line determinant of trust, retention, and successful long-term partnership.
A System Under Strain
The structural pressures that clinical research sites face have been well documented for years. Many operate on thin financial margins, with limited cash reserves and growing administrative demands.
Recent studies have shown that approximately 80% of sites have just six months or less of operating cash on hand, making timely payments not only important, but essential to their survival.
“Cash flow is a huge hurdle,” said Melissa Easy, chief operating officer at TrialScreen. “If we’re not paying sites in a timely manner, shame on us.”
These financial realities are compounded by increasing trial complexity. Modern studies—particularly those in oncology, rare disease, and cell and gene therapy—often require extensive data capture, coordination across multiple systems, and increasingly sophisticated infrastructure.
Sites are asked to manage this complexity while also navigating the fragmented payment processes and unclear financial terms that have hampered their work for decades. Predictably, the result is mounting strain.
Sites are doing too much, with less predictability and, in many cases, delayed compensation. In fact, a white paper by the Society for Clinical Research Sites indicated that over 70% of sites experience financial stress, often causing them to take out loans or engage in other drastic measures to complete their work while waiting for reimbursement.
Reinventing the Wheel, Again…and Again
One of the most persistent challenges faced by sites is inconsistency. Payment structures, contract terms, and budgeting approaches vary widely across sponsors and studies, creating confusion and inefficiency.
“Every project has different designs and nuances,” said Justin Purvis, senior director of Site Contracts and Payments at PPD. “It brings new life to every situation, and we have to be adaptive.”
Inconsistency inevitably creates a ripple effect on sites, where they must interpret new payment terms for every study, often without clear guidance. Budget negotiations become prolonged and payment expectations remain uncertain until well into a trial’s execution.
Even foundational concepts such as fair market value (FMV) are often unclear. And although FMV frameworks were designed to standardize compensation, they can often lag real-world conditions.
“FMV data is typically out of date by the time you are negotiating a contract,” explained Theo Emmanuel-Mari, senior director of Clinical Outsourcing, Site Contracts & Payments at Jazz Pharmaceuticals. “We are seeing costs that have no benchmark at all.”
This gap forces both sponsors and sites to become reactive, negotiating without reliable reference points, and even sometimes revisiting assumptions mid-study—causing costly interruptions and delays.
The Transparency Gap
If inconsistency is the root problem, lack of transparency is its most visible symptom. Sites frequently report receiving payments with little or no explanation: no clear linkage to patients, visits, or procedures. Despite advances in technology, this issue remains persistent.
“I was blown away when a check would just arrive at the site, and we had no idea what it was for,” Easy emphasized. “With all the technology we have, this still happens.”
Such opacity creates administrative burden, forcing sites to manually reconcile payments and track discrepancies. More importantly, however, it erodes trust.
Transparency is not simply about visibility, it is about predictability. Sites need to know what they will be paid, when they will be paid, and how those payments are calculated. Without such clarity, even well-intentioned payment processes can become a source of friction.
Payment Terms Cause Tension in Important Site Relationships
Today’s payment practices continue to generate outsized frustration. In some cases, they can even drive sites away entirely. Particularly contentious are holdbacks. While intended to ensure compliance or performance, holdbacks can create significant financial strain for sites.
“If a site is good enough to be selected for a study, why not trust them to be paid when they’ve done the work?” Easy said.
In extreme cases, holdbacks can reach up to six figures, effectively forcing sites to self-finance large portions of trial activity. And while some sponsors are beginning to reduce or eliminate holdbacks, they remain embedded in many contract templates.
Additionally, overly complex payment structures, such as those tied to detailed procedural calculations, can create confusion and delay.
“In trying to be fair, sponsors sometimes unintentionally make payment terms so complex that it is nearly impossible to untangle and figure them out,” Easy added.
These issues are not merely operational, as they have long-term, relational impacts as well. Site administrators remember which sponsors create friction, and which collaborations were easier.
Over time, those experiences will undoubtably shape site preferences and influence future study participation. Sponsors who don’t manage these issues well could find themselves out in the cold.
Communication as a Competitive Differentiator
When asked what separates sponsors that sites prefer from those they avoid, the answers are often the same: transparency, accessibility, and responsiveness.
“If I’m a site with a payment problem, I need to know who I can go to in order to resolve it fast,” Purvis said. “It should not take six months or multiple people to find a solution.”
Emmanuel-Mari echoed this perspective, emphasizing the importance of direct engagement.
“Sites get frustrated when they cannot speak to a sponsor directly. Having a clear point of contact—even for escalations—makes a huge difference,” he said.
Proactive communication is equally important. Informing sites of anticipated delays, explaining underlying causes, and setting realistic expectations can help mitigate frustration.
“Sites understand that things go wrong,” Emmanuel-Mari added. “Providing transparency and realistic timelines often ease a lot of tension.”
In this context, communication is more than just a courtesy, it’s a strategic requirement.
The Human Impact
Delayed or unclear payments affect more than accounting workflows. They also influence staffing decisions, morale, and the ability of sites to support patients effectively.
Financial uncertainty can force sites to reduce services, delay hiring, or even reconsider participation in future trials. And it is patients who suffer the most when potential breakthrough therapies get delayed by contractual nuance.
Conversely, when payment processes are clear and reliable, the benefits are often immediate. Sites can focus on patient care, data quality improves, and partnerships strengthen.
Payments are not just an administrative function but are also a key enabler of research.
From Operational Detail to Strategic Priority
The payment experience is no longer a secondary concern in clinical trials. Historically, sponsors have measured success through enrollment metrics, timelines, and data quality.
But until sponsors track payment metrics with the same vigilance as enrollment, nothing will change. Payments are a strategic priority today.
Most importantly, site payment inequity is increasingly untenable. In a constrained site environment, where experienced investigators are in high demand, payment experience can determine whether a sponsor becomes a preferred partner or is excluded from future opportunities.
In fact, the American Society of Clinical Oncology (ASCO) reported 6,710 open trials in 2024 across just 1,836 sites, showing a ratio of approximately 3.7 trials per site. This disproportionate site-to-trial ratio is growing, especially with the increased need for specialty sites that have experience in novel sciences such as cell and gene therapy and radiopharmaceuticals.
And sites are not interchangeable vendors, they are long-term collaborators with institutional knowledge, patient relationships, and operational expertise. Retaining them requires more than competitive budgets, it requires a consistent, transparent, and responsive financial experience.
A Path Forward
Addressing these challenges will require a coordinated effort across the clinical research ecosystem. Although no single solution can resolve all issues, here are five critical priorities:
- Standardization, where possible. Reducing variability in payment structures and contract terms can streamline processes and reduce confusion.
- Transparency by design. Payment systems should provide clear, real-time visibility into what has been paid, what is pending, and why.
- Flexible engagement models. Recognizing that sites operate differently, and allowing for varied workflows, can reduce friction and improve adoption.
- Proactive communication. Establishing clear points of contact and maintaining open dialogue can prevent small matters from escalating into big issues.
- Measurement and accountability. Treating payment performance as a key metric, alongside enrollment and timelines, will drive meaningful change.
Ultimately, improving the payment experience is not about incremental optimization. It is about rethinking how sponsors and CROs engage with sites as a rule.
What’s Really at Stake Today
As clinical trials continue to grow in complexity and demand, the availability of experienced sites will remain a critical limiting factor. Sites that feel undervalued, overburdened, or underpaid have options. They can—and will—decline future studies.
Conversely, sponsors that prioritize site experience, including payments, will gain a competitive advantage. They will build trust, strengthen partnerships, and secure access to the sites best equipped to deliver high-quality research.
In this increasingly competitive environment, payment experience is no longer a liability to manage. It is an opportunity to differentiate. And for an industry built on partnership, that distinction may determine not only who conducts the next trial, but how quickly new therapies reach the patients who need them.