For some physicians, ASC ownership has been thought of as a simple investment in which their main responsibilities include investing capital, completing the work and collecting a distribution.
While that model does exist, some ASC leaders say it rarely works the way physicians imagine — and the gap between expectation and reality is where profitability quietly leaks out.
“Ownership means exposure,” Scott Freer, clinical administrator of ASC Bala Cynwyd (Pa.), told Becker’s. “It means that when the facility’s billing department is underperforming, that’s your problem. When a key scrub tech quits and you can’t staff cases for two weeks, that’s your problem. When Medicare audits a few years of claims and wants money back, that’s your problem. The distributions that look so attractive in the pro forma come after all of that.”
The assumption that hiring an administrator or signing with a management company frees an owner to be passive is, in Mr. Freer’s view, the most expensive misconception in ASC ownership.
“The administrator answers to the board. The management company has a contract. Neither of them cares as much about your facility as you do — because it’s your name, your license and your capital at risk,” he said. “Effective ASC owners stay engaged with operations at a level that surprises most physicians. Not micromanaging — there’s a difference — but genuinely understanding the numbers, holding leadership accountable and making strategic decisions that compound over years.”
Shakeel Ahmed, MD, CEO of St. Louis-based Atlas Surgical Group, has watched the same disconnect play out at the case level. In a recent column for Becker’s, Dr. Ahmed described a widening gap between the mindset of an ASC’s “users” and its owners, particularly as margins that once ran in the 30% range have compressed to the low single digits.
“I have been part of countless discussions, both in private and in boardrooms, with surgeons complaining about the lack of distributions while simultaneously insisting on using a proprietary suture that costs four times the market average because ‘that is what I am comfortable with,’” Dr. Ahmed wrote. “But what they don’t realize is that, in an ASC, that’s coming directly out of their own pocket. We will have to stop shielding our partners from the ‘ugly’ side of profit and loss.”
His remedy has been radical transparency with his own physician partners. “At our Atlas franchise, I have found that transparency is the best medicine for entitlement,” he wrote. “When surgeons see the line-item costs of their specific cases compared to their peers, the competitive nature that got them through med school kicks in.”
Benjamin Stein, MD, an independent orthopedic surgeon and co-founder and chairman of ASC development group Capital Surgical Solutions, has urged physicians to make the same mental shift before they ever sign on as owners.
“Surgeons shouldn’t view a surgery center as just a passive site of care,” Dr. Stein told Becker’s In 2025. “It’s an extension of their practice. The same way they take methodical control over the patient experience in their office.”
For Mr. Freer, that engagement is also the clearest predictor of which physicians thrive as ASC owners. “They’re genuinely curious about the business,” he wrote. “They want to understand why their collection rate is what it is, what their cost per case looks like relative to peers, and what the payer mix trend line has looked like over the past three years. They ask questions that their administrator sometimes has to go look up. That curiosity is not a burden on the facility — it’s a forcing function for accountability.”
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.