The push to move cardiac procedures out of hospitals and into ASCs has generated excitement across the industry, but many leaders say the reality is far more demanding than the conversation suggests.
Amanda Ryan, DO, interventional cardiologist and CEO of Advanced Heart and Vascular Center of New Mexico in Carlsbad, is a genuine believer in the model, particularly for rural and underserved communities where cardiac access is a persistent problem.
“In our rural area, it’s a perfect fit for bringing top-level care to an area that would otherwise not get this kind of service,” she said.
But Dr. Ryan is clear that the reality is far more complicated and demanding than ASCs might understand.
“Everyone’s talking about it like it’s going to be the latest greatest thing,” Dr. Ryan said. “And I think it can be — but what’s involved is way more than what people realize.”
The regulatory maze
The regulatory path for cardiac ASCs is complicated and varying. State-by-state variance means even well-prepared teams can be caught off guard by shifting rules.
Dr. Ryan learned this firsthand. One misstep — applying to the state before pursuing deemed status — cost her facility roughly five months. The fix came not from consultants, but from a local government representative who understood the specific agency relationships involved.
“Nobody knows each individual state and every nuance,” Dr. Ryan said, “and as soon as you think you do, something changes in the rules and regs.”
Her advice to other ASC leaders is to build a direct relationship inside the relevant state agency and not to rely solely on outside guidance.
“Consultants are very helpful and give you a lot of good information,” she said, “but at the end of the day, it’s your internal team that needs to do the work.”
The training investment
The most underappreciated barrier to a successful cardiac ASC could be the volume of training required before a single high-risk case should be scheduled, Dr. Ryan said.
Her facility spent 18 months training staff at approximately 20 hours per week, on top of everyone’s existing full-time responsibilities, before opening its cardiovascular program.
Adding electrophysiology services required another year of 20 to 30 hours of weekly training, with the ASC intentionally running at 50% capacity to protect patient safety during the transition. The EP build cost approximately $2 million.
According to Dr. Ryan, there is a difference between doing cardiac cases and building a cardiac program.
“You’re not just doing some cases,” she said. “You have to invest in the infrastructure. You need workflows, diagrams, outside training, support from your accrediting agencies. You need to be submitting to registries.”
For ASCs in markets where hospital staff can be recruited from existing cardiac programs, the lift is somewhat lighter. But for facilities in rural areas introducing a service line that doesn’t exist locally — Dr. Ryan’s facility serves a region where comparable care was 150 miles away — the build is essentially from scratch.
Clinical leadership is a necessity
As management companies and private equity increasingly enter the ASC space, Dr. Ryan said that physician involvement is essential to doing this responsibly.
“We cannot let this be a pure PE management company, hospital system situation,” she said. “Clinicians have to be involved.”
Her facility recently merged with a management company to expand its EP program, but structured governance carefully. The partnership requires supermajority board votes for major decisions and keeps clinical authority in physician hands.
That structure matters. When CMS broadly approved ablations for ASCs without specifying required devices, it opened the door to older, less expensive technology. The newer standard, pulse field ablation, carries a meaningfully better safety profile for atrial fibrillation procedures but costs significantly more. Dr. Ryan estimates that choosing the clinically superior option represented a $1.5 million to $2 million difference for her facility.
“As a clinician, you have to be careful when you’re looking at those decisions,” she said. “We made the decision that was the best per clinical opinion” — one made by electrophysiologists she describes as among the top in the country. That kind of judgment, she argues, is difficult to replicate when business considerations are driving the room.
The reimbursement math
On paper, cardiac procedures in the ASC setting look financially attractive. In practice, the margins are narrow enough that a single non-routine case can erase the profit on several that went smoothly.
Dr. Ryan estimates her facility operates at around 15% profit margins on cardiovascular procedures. “Using up extra supplies can really limit that very quickly,” she said. “It’s not the same as bringing in several million and having a 10 to 15% margin. It’s pretty narrow.”
Compounding the problem is device vendors have little incentive to offer ASCs meaningful discounts. High demand, combined with concerns that lower ASC pricing would undercut hospital contracts, means facilities are largely paying full price.
For Dr. Ryan, the question every ASC leader should be asking before entering cardiac space is whether the infrastructure exists to deliver them safely and sustainably.
“You’ve got to do a fair market assessment and really look at the volume you need in order to cover the cost,” she said. “This is not just a financial opportunity. This is an access opportunity. And that’s how we need to really look at it.”
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.