More physicians are moving procedures out of hospitals and ASCs and into freestanding, cash-pay, office-based surgery centers, a shift plastic surgeon Heather Levites, MD, attributes to lower buildout costs and a growing comfort with lighter anesthesia.
The share of surgeons operating in an office-based surgery suite jumped to 6% in 2025, up from 2% the year before, according to the American Society of Cataract and Refractive Surgery’s 2025 Clinical Survey.
Dr. Levites is the founder of Levity Lifts, a private, cash-pay plastic surgery practice in Raleigh, N.C. Because her practice doesn’t accept insurance, it didn’t need to be coded as an ASC, which she said is a distinction that spared her from far more expensive construction requirements.
“If you want to accept insurance, like Medicare, Medicaid specifically, you have to follow an increased, more constrained set of regulatory conditions,” she said. “An office-based surgery center, which is not coded the same way as an ambulatory surgery center for the purposes of coding, is not held to the same sort of architectural constraints.”
That meant she didn’t have to install piped gases, wall suction or other costly infrastructure standard in ASCs. The gap shows up clearly in construction budgets: office-based suites typically run $120 to $220 per square foot to build, compared with $350 to $900-plus per square foot for an ASC, and a full ASC build can take one to two years and cost up to $2 million, according to a report from iOR Partners, a physician-owned company company geared towards shifting ophthalmic procedures towards office settings. Dr. Levites credited colleagues in her market for steering her away from those expenses during buildout.
“I was saved from creating or upcoding my space to an ambulatory surgery center,” she said. “There are a couple other very expensive things that I did not have to purchase because of advice from colleagues.”
Capital costs are only part of the equation, according to Dr. Levites. She said plastic surgery in particular has shifted toward lighter anesthesia, a trend that plays directly into the office-based model.
“We’ve become more comfortable doing surgeries with less anesthesia,” she said. “There’s this movement towards twilight anesthesia, or even full local anesthesia, for procedures, because the patients recover faster. There’s less risk of big complications of general anesthesia, like deep vein thrombosis, or other anesthetic-related complications, like laryngospasm, because you’re not putting tubes in people.”
For most procedures, Levity Lifts uses twilight sedation administered by a certified registered nurse anesthetist rather than general anesthesia, which Dr. Levites said is a model that also helps her navigate the broader anesthesia provider shortage. The U.S. has about 52,300 practicing anesthesiologists and is projected to be short 6,300 of them by 2036, according to a 2025 Medicus Healthcare Solutions analysis.
CRNAs face a similar squeeze, with a projected shortage of 12,500, about 22% of the current workforce, by 2033. The strain is already showing up in ASC budgets nationally: the share of surgery centers paying anesthesia stipends jumped from 28% in 2024 to 44% in 2025, according to VMG Health.
“There’s a level of comfort for patients knowing that yes, I have a CRNA, but the CRNA is also not putting me fully to sleep,” she said. “So it’s more like a colonoscopy than anything else.”
About 2,000 facilities nationwide are now accredited by the American Association for Accreditation of Ambulatory Surgical Facilities, which, along with the American Society of Plastic Surgeons, requires its members to operate only in accredited or licensed facilities. That growing accreditation infrastructure is one sign the office-based model has matured well beyond a cost workaround for individual practices like Dr. Levites’s.
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.
