Implants may be the biggest line item in an orthopedic practice, but they are rarely the costs that catch leaders off guard.
At Becker’s 32nd Annual Business and Operations of ASCs conference in Chicago, orthopedic surgeons and ASC administrators described the smaller, less visible expenses that add up across hundreds of cases a year. Here are eight hidden costs leaders flagged, along with what recent Becker’s reporting shows.
1. The disposables no one thinks about
Implants make up about 42% of expenses at Sebring, Fla.-based Bone and Joint Surgical Suites, a single-specialty orthopedic ASC that opened about three years ago, said J.C. Alvarez, MD, the center’s medical director and an orthopedic surgeon. The bigger surprise, he said, was everything else.
Dr. Alvarez pointed to Stryker spacesuits, multiplied across four people on a case. He also pointed to cement mixing. At the hospital, he used a powered mixing gun that cost $120, plus $75 per cement bag. At the ASC, he switched to a mixing bowl and uses one bag instead of two on smaller knees, which he said saves about $125 per case. Across seven cases in a day, that adds up quickly.
“Be careful with the things you don’t think about, because they’re going to get you,” Dr. Alvarez said he tells surgeons opening ASCs.
2. Implant prices surgeons never see
Many surgeons don’t know what their ASC pays for the implants they choose, said Shobhit Minhas, MD, an orthopedic surgeon at Geneva, Ill.-based Fox Valley Orthopedics. About a year ago, his group sent surgeons a breakdown of implant costs and facility reimbursement for common procedures.
Dr. Minhas said the transparency changed some surgeons’ behavior. When surgeons learn that a comparable implant could save $1,000 to $2,000 per case, many are willing to switch. He also pointed to supplies such as drapes, scrubs and sutures as easier savings that don’t affect patient care.
Lori Callahan, regional ASC director at Rockford, Ill.-based OrthoIllinois, said ASCs should use their spending as leverage. One vendor that her organization spends about $6 million a year with offered equipment such as overhead lights and sterilizers in return, Ms. Callahan said.
3. Minimum purchase requirements
Nyleen Flores, administrator and COO of Greensboro, Ga.-based Lake Oconee Orthopedics, said vendor minimum-buy requirements can catch smaller ASCs off guard. Those minimums are often set with large hospitals in mind, not centers with two or three operating rooms, she said.
4. Payer contracts stuck in the past
Some orthopedic ASCs are still paid under contracts built on decades-old methodology, Ms. Callahan said. Some payer contracts reimburse only a few CPT codes per case under grouper methodology dating back to around 2000. Payers have also begun clawing back payments for items ASCs expected to be covered.
Ms. Callahan’s organization hired a contracting specialist who previously worked at UnitedHealthcare. She said sending a termination letter is often what gets a payer to the table, even when the goal is not to end the contract.
Ms. Flores recommended hiring a third party for a one-time renegotiation, especially for centers that have been open 10 to 15 years. She said ASCs should then confirm that payers actually loaded the new rates.
Payer friction starts before the case, too. Christopher Yeung, MD, of Phoenix-based Desert Institute for Spine Care, previously told Becker’s that nearly every surgical case at his practice requires prior authorization and about 30% are initially denied. Depending on the payer, another 10% to 15% of charges are denied after surgery.
5. Technology that keeps costing after you buy it
Getting a robot placed at no cost doesn’t mean it’s free. Ms. Callahan said her organization didn’t pay for a robot placed for its spine surgeons but does pay about $145,000 a year in maintenance.
Robot disruptions also cost time. A study in the January 2026 issue of The Spine Journal found that adverse events involving the Mazor X and Excelsius platforms caused a mean procedural delay of 58.1 minutes. None of the 189 modeled scenarios reached financial break-even within the systems’ seven-year useful life.
Panelists recommended tying any new technology to case volume and margin per minute, and negotiating an exit. Dr. Minhas suggested a 30- to 60-day “kill switch.”
6. Overstaffing carried over from the hospital
Dr. Alvarez’s ASC tracks staff hours per OR hour. About a year ago, it was at 20, well above the benchmark of 12 to 15 the center was given. He said an administrator who came from the hospital had brought a hospital staffing mindset with her. The center is now at 14, which he said translates to a significant reduction in staffing costs.
To keep the math simple for surgeons, his center’s finance team uses a figure of about $1,000 per OR hour. By that measure, shaving five minutes off each knee across nine cases saves 45 minutes in a day.
7. Cancellations
Cancellations are the biggest weak spot at Dr. Alvarez’s ASC, which averages 45 to 55 cancellations a month. Many of those are smaller pain cases, but every empty slot still carries fixed costs.
8. The ‘invisible factory’ behind every case
Ahilan Sivaganesan, MD, director of minimally invasive spine surgery at Penn Medicine in Philadelphia, asked the panel about a cost that rarely shows up in case costing: the sterile processing, equipment handling and logistics behind each procedure. He calls it the “invisible factory.”
Ms. Callahan and Ms. Flores said those costs typically sit in fixed overhead and are spread across OR minutes rather than assigned to individual cases. Dr. Sivaganesan is launching a study at Penn to trace the true production costs of lumbar decompression and lumbar fusion.
The bigger picture
These operating costs come on top of broader pressure on spine and orthopedic practices. Kurtis Biggs, DO, founder of Naples, Fla.-based Joint Replacement Institute, previously told Becker’s his practice’s overhead climbed from 47% to nearly 70% over five years.
Panelists said the response starts with visibility. “Transparency” was Ms. Callahan’s one-word takeaway. Her centers send surgeons monthly reports showing their contribution per minute by specialty and location.
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.
