As ASCs push into higher-acuity care, leaders say the most underestimated threat isn’t demand, it’s the widening gap between rising labor, supply and anesthesia costs and shrinking or misaligned reimbursement.
Executives warn that compressed professional fees, staffing shortages and growing payer and regulatory complexity are straining reliability and margins, making long-term performance depend more on workforce sustainability and operational standardization than expansion.
Question: What pressure on ASCs do you think is being underestimated at the moment?
Editor’s note: Responses have been lightly edited for clarity and length.
Robert Aycock, MD. Founder and Medical Director of Greenbrae Surgery Center (Larkspur, Calif.): I believe the insurance rates given to ASCs is being underestimated. The increases, if any, are not in line with the increases that the staff are requesting and/or increases in supplies and equipment.
John Beauchamp. Senior Director of Administration, Revenue Cycle and Data Analytics at GI Associates (Milwaukee): 2026 is off and running. There are so many competing pressures right now. One of the most underestimated pressures on ASCs is the erosion of fair reimbursement for physician and anesthesia services. It’s just not low rates, but a structural misalignment where professional fees are being compressed while ASCs are expected to deliver higher efficiency, access and quality. When physician and anesthesia economics weaken, the ASC model becomes fragile.
Anesthesia, in particular, is becoming more and more of a limiting factor, and that risk is grossly underappreciated. It’s been a real challenge for us to recruit and retain anesthesiologists and CRNAs due to low reimbursement.
Peter Bravos, MD. Chief Medical Officer of Sutter Health’s Surgery Center Division (Sacramento, Calif.): ASCs continue to grow, but rising operational complexity from higher acuity cases, stricter payer requirements and evolving workforce expectations [are] creating friction that volume and reimbursement no longer accommodates.
This leads to reduced reliability, day-of-surgery disruptions and subsequent margin pressure. Going forward, sustained ASC performance will depend less on expansion and more on standardization, governance and data-driven decision making to reduce variability and preserve the advantages of the ASC model.
Joe Carlon. President at Desert Spine and Sports Physicians (Phoenix): ASCs are underestimating the resources required to recruit, train and retain staff to support the migration of cases out of the hospital and into the ASC. If you don’t have nurses, techs and support staff who understand the unique requirements of your given specialty, you are going to have a hard time maintaining physician satisfaction and patient outcomes will suffer.
Kevin Curtis. Practice Administrator at Richmond Heart & Vascular Associates (Mechanicsville, Va.): The ability to fund future growth. Banking options are limited and private equity expects too much control.
Wayne Gillis. President and CEO of Rehoboth McKinley Christian Health Network (Gallup, N.M.): One underestimated pressure on rural ASCs is workforce sustainability, not just staffing. Rural ASCs rely on small, highly flexible teams of perioperative nurses, anesthesia providers and techs who cover multiple roles, but that model is breaking as workforce expectations shift toward predictable schedules, flexibility and work-life balance. With already-thin labor pools, this is becoming an existential issue.
Margins are also tightening as labor and supply costs rise while reimbursement lags, leaving little room to invest in training, cross-coverage or retention. Trying to make up the difference with more volume can accelerate burnout and reduce capacity.
At the same time, rural ASCs are being asked to take on higher-acuity cases as hospitals downsize inpatient services, increasing operational and clinical risk without deliberate investment in skills, staffing models and support. Leaders may focus on volume and reimbursement, but the real constraint is a fragile workforce model built for a different era. Long-term sustainability will depend on redesigning roles, schedules and expectations to match today’s workforce reality.
Barry Glaser, MD. Surgeon at Abington Surgical Center (Willow Grove, Pa.): The Abington Surgical Center was first established in 1989, being one of the first surgical centers in the Philadelphia area and recently being selected as a No. 1 multi-specialty center in Pennsylvania by Newsweek.
Over the years, the main problems that we encountered were related to shrinking reimbursements by Medicare and the insurance companies. More recently, we are faced with increasing costs in almost every area, including purchasing of materials, insurance costs, maintenance and rising salaries of both nurses and ancillary staff workers. Currently, we are facing an extraordinary increasing cost for anesthesia services.
This is an overall problem, not only in outpatient surgery, but in hospitals as well. Taking all of these factors into consideration, it has become increasingly challenging for our center, and others to maintain a positive margin. If I were to choose one major issue, it would be the significant increase in anesthesia services cost.
Paul Lynch, MD. Anesthesiologist and CEO at U.S. Pain Care (Phoenix): One pressure that is being underestimated is the rapid increase in labor costs driven by higher demand and reduced supply for key ASC personnel, particularly nurses, anesthesia providers and specialized technical staff like radiology techs.
As ASCs take on more complex cases, they increasingly require experienced perioperative teams, yet the available workforce has not kept pace. Competition from hospitals, health systems and locum agencies has pushed compensation higher, especially in anesthesia, while reimbursement has remained relatively flat. That imbalance is creating meaningful margin pressure for ASCs and, in some cases, constraining growth simply because reliable, affordable staffing is harder to secure.
Randy Quinn, CRNA. Chief Compliance and Integration Officer at Guide Anesthesia (Phoenix): The greatest pressure facing ASCs today remains the anesthesia provider shortage, with increased reliance on locum tenens providers significantly straining operating budgets.
To address this, ASCs should modernize outdated bylaws and privilege delineation to allow CRNAs to practice to the full scope of their education and training, while removing unnecessary practice restrictions. Enabling both physician anesthesiologists and CRNAs to function at the top of their licenses is essential to mitigating workforce shortages.
ASCs should also consider partnering with physician and CRNA training programs to provide clinical training opportunities. Many anesthesia providers have limited exposure to the ASC setting during training, which reduces post-graduation interest. These partnerships not only expand the workforce pipeline but also serve as effective long-term recruitment strategies.
Amanda Ryan, DO. Interventional Cardiologist at Advanced Heart and Vascular Center of New Mexico (Carlsbad): Patients, facing high-deductible health plans, are increasingly cost-conscious. The power of this consumer demand for cost-effective, transparent care is a driving force that ASCs can leverage, though many may underestimate its long-term impact on market dynamics.
Teresa Tam, MD. Minimally Invasive Gynecological Surgeon and Owner of All for Women Healthcare (Chicago): I think the biggest underestimated pressure right now is the gap between reimbursement and actual costs. Medicare rates are barely keeping pace as costs for implants, devices and supplies rise exponentially each year. And on the commercial side, payers know ASCs are more cost-effective than hospitals, but they’re using that as leverage to drive rates down instead of recognizing the value, which seems counterproductive.
The administrative burden keeps growing, too, expanding regulatory requirements and prior authorizations that require considerable staff time without any compensation for that work. ASCs are expected to meet increasingly complex regulations while facing flat or declining reimbursement. These combined pressures are really squeezing margins, particularly for independent centers without health system backing.
