ASCs have long stood as a clear value proposition within healthcare — delivering lower costs, high patient satisfaction and streamlined care — but leaders say the model is facing mounting strain as financial, workforce and competitive pressures converge.
While outpatient migration continues and demand remains strong, ASC operators describe a business environment defined by reimbursement compression, rising labor and supply costs, anesthesia coverage challenges and intensifying competition for physicians.
Four leaders joined Becker’s to discuss what they see as the biggest threat to the ASC model right now and what it will take to sustain its growth.
Editor’s note: Responses were edited lightly for clarity and length.
Question: What’s the biggest threat to the ASC model right now?
Bonnie Greenblatt. Director of Ambulatory Surgical Services at Michigan Institute of Urology (St. Clair Shores): The biggest threat is the growing gap between declining reimbursement and rapidly escalating costs. Reimbursement rates continue to tighten, while expenses — particularly supplies and staffing — are steadily increasing. The rising cost of surgical supplies, implants and pharmaceuticals, combined with competitive wage pressures and staffing shortages, places significant strain on margins. This imbalance creates ongoing financial pressure and challenges our ability to maintain operational efficiency, invest in improvements, and deliver the high-quality patient care we strive for.
Addressing this requires disciplined cost management, strong vendor partnerships, optimized scheduling and throughput, and continued collaboration with physicians to ensure sustainability in an increasingly challenging reimbursement environment.
Megan Friedman, DO. Chair and Medical Director at Pacific Coast Anesthesia (Los Angeles): The biggest threat is reimbursement compression combined with the shift of anesthesia from a variable expense to a fixed cost. Anesthesia is no longer a per-case service where physicians absorb downtime; coverage is structured and shift-based to ensure reliability and workforce stability. When volume fluctuates, the expense does not decrease with it. It is spread across fewer cases, increasing cost per case and narrowing margins. In this environment, disciplined scheduling and stable anesthesia coverage are essential to preserving financial performance.
David Jevesevar, MD. CEO of OrthoVirginia (North Chesterfield): The ASC model is one of the great success stories in American healthcare — lower cost, better outcomes, higher patient satisfaction. But the model is under real pressure, and I think the biggest threat isn’t what most people assume. It’s not reimbursement cuts in isolation. It’s the convergence of rate pressure, case mix drift and workforce cost escalation happening simultaneously.
Here’s what keeps me up at night: when you layer in the nursing and anesthesia shortage driving labor costs upward, the continued escalation of implant pricing, and then add the ongoing threat of physician employment by health systems that depletes the surgeon supply chain feeding independent ASCs, the structural foundation starts to look more fragile than the headline numbers suggest.
For orthopedic ASCs specifically, total joint arthroplasty was supposed to be the growth engine. And it has been — but that opportunity is maturing faster than many anticipated, and CMS rate parity with HOPDs remains incomplete. If independent practices can’t maintain the physician ownership and case volume that make the economics work, consolidation becomes the path of least resistance. That’s not a win for patients or the system.
The threat isn’t a single policy change. It’s death by a thousand cuts. And the antidote is independent practices staying integrated, staying vigilant and staying at the table in policy conversations.
Cori Rist, RN. Administrator of Optimum Spine Center (Atlanta): I do not see a major threat to the ASC model. If anything, it’s one of the strongest growth areas in healthcare. Cases continue to migrate to the outpatient setting; patients prefer it, and payers favor the lower cost and convenience. The real pressure point is staffing.
It’s not just filling positions; it’s finding experienced candidates who understand efficiency, safety, the pace of the ASC, and continued operational growth expectations. When you’re running lean by design, one resignation, one disengaged team member, or one breakdown in leadership can impact flow, overtime, morale, and ultimately margins. The centers that stay ahead are the ones investing in culture, cross-training, leadership development and retention, not just recruitment.
