From assumptions about surgical volume to the role of anesthesiologists, ASC leaders discuss ideas they’ve unlearned in recent years.
Note: These responses were lightly edited for clarity.
Question: What’s one assumption about your patients, your practice, or your field that you’ve had to unlearn in the last two years?
Sean Gipson. CEO and Division president of ASCs at Remedy Surgery Center (Hurst, Texas): The ASC assumption that quietly broke is more volume equals more profit. For years, ambulatory surgery centers operated under a straightforward premise: increase case volume and profitability will follow. But over the past two years, that assumption has quietly unraveled.
The ASC leaders who are still measuring success primarily by case growth may be missing a more uncomfortable reality: not all volume is good volume, and some of it is quietly unprofitable.
Several converging pressures have disrupted the traditional volume-driven model. One of the first factors is that the payer mix is shifting quickly. Commercial reimbursement, the previous financial backbone of ASCs, is under increasing pressure. At the same time, Medicare and Medicare Advantage volumes are rising and the result, even as total cases increase, is revenue per case is declining.
Another factor is that the wrong cases are moving the fastest. The industry anticipated a migration of higher-acuity procedures into ASCs. While that is happening, the fastest growth has come from lower-acuity, lower-reimbursing cases, diluting our overall margins. Additionally, labor costs are no longer variable. Staffing was once a lever that could flex with volume. Today, labor costs are structurally higher and far less responsive. Premium pay, contract labor, and retention investments mean that incremental cases don’t carry the same margin they once did.
Supply costs that come with higher acuity cases are eroding contribution margins. Implants, pharmaceuticals, and disposable supplies have seen sustained cost increases and reduced availability in many cases. Without aggressive supply chain management, case-level profitability can disappear, even in high-volume environments.
Throughput does not equal profitability. Many ASCs still optimize speed and block utilization without fully understanding profitability at the case or surgeon level. High utilization of low-margin blocks can create the illusion of performance while masking financial underperformance. It’s painful at the end of a large-volume day that results with the same margin on a two-procedure spine day.
The new operating reality is high-performing ASCs are shifting away from volume as the primary success metric and instead, focusing on case mix index optimization, payer contracting and alignment strategies, profitability by surgeon, service line and block time and cost discipline at the case level.
This is a much more complex operating model, but it is also a more honest one. Operators that do not understand their numbers on this complex level are going to be left behind in today’s competitive industry.
The bottom line is that the ASC market hasn’t lost its growth story, but it has lost its simplicity. Leaders who continue to chase volume without interrogating their margins are at risk of scaling inefficiency. Those who adapt by aligning growth with profitability will define the next phase of ASC performance. Because in today’s environment, more cases don’t guarantee better outcomes, financially or operationally.
Megan Friedman, DO. Chair and Medical Director of Pacific Coast Anesthesia Consultants (Los Angeles): One assumption I’ve had to unlearn is that our role as anesthesiologists is limited to clinical care inside the operating room.
In reality, being a strong clinician is no longer enough. Anesthesia sits at the center of perioperative operations, with visibility across the OR, GI, cath lab and other procedural areas. We see, in real time, how cases move, where delays occur, and where inefficiencies exist.
Over the past two years, it’s become clear that when anesthesia is not actively involved in operational planning, decisions are made without a full understanding of how the system actually functions. The highest-performing environments are the ones that leverage anesthesia not just for patient care, but for throughput, scheduling alignment, and day-to-day operational decision-making.
The shift is recognizing that anesthesia is not just a clinical service. It is a key operational partner, and being effective today requires both clinical excellence and active engagement in how the system runs.
Nikolas Jannetta. Director of Operations at National Spine and Pain Centers (Miami): A healthy financial margin and a full patient schedule makes a healthcare practice successful. At least, that has always been the assumption. As director of operations for multiple interventional spine centers and associated ASCs in the Southeast, establishing a scalable business model that prioritizes best-in-class clinical outcomes is the principal focus. Leveraging advanced technology to enhance physician decision-making is the first step toward the goal of making both our patients and our financial margins healthier.
When met with operational knowledge or performance gaps, incorporating an automated systems-based approach can increase detection and response time to suggest proper evaluation or action, alerting physicians to potential unseen operational or knowledge gaps, without over-burdening the team or requiring increased labor costs. The deliberate design of an autonomous yet collaborative administrative engine empowers physicians while preserving their unwavering autonomy over decision-making. While physicians are still at the core of every decision-making process, their abilities and clinical outcomes are enhanced by partnering with the power of technology, without compromising financial margins.
Paul Lynch, MD. Founder and CEO at US Pain Care (Scottsdale, Ariz.): One assumption I’ve had to unlearn is that standardizing physicians leads to better outcomes and efficiency. For years, we’ve tried to make doctors practice the way we think they should — same protocols, same workflows, same expectations. What we’ve learned at US Pain is that this approach often suppresses performance rather than improving it. Physicians aren’t interchangeable units — they have different strengths, philosophies, training and clinical instincts. When you force uniformity, you lose the upside of what makes great doctors great.
Instead, we’re starting to build systems around the individual physician. Using tools like predictive modeling and behavioral profiling, we can understand how each doctor naturally practices — and then design the clinic, staffing, service lines, and even scheduling around that. The result is better outcomes, higher efficiency and lower burnout. The future of ASC operations isn’t forcing doctors into a system — it’s building a system that reflects the doctor.
Michael Verdon, DO. President at Dayton (Ohio) Neurological Associates: There is an assumption embedded in most discussions of spine care delivery that needs to be challenged: that the system, while strained, is fundamentally intact. It is not. The post-COVID environment has been altered in ways that will not self-correct, and our patients are absorbing the consequences without understanding why.
Three forces deserve more honest discussion among those of us running spine practices and programs.
The clinical brain drain is permanent, and it starts upstream of us. The mid-to-late career exodus from primary care between 2021 and 2024 was not a staffing event. It was a loss of clinical judgment that no workforce model captures. The internists who retired early were the ones who knew when to escalate, who had the relationships to get a patient in front of us in days rather than months, and who could distinguish mechanical pain from a red flag at the bedside. Their replacements are capable, but the institutional pattern recognition is gone. Patients now arrive at our clinics later, more deconditioned, with incomplete conservative trials and imaging ordered defensively rather than diagnostically. The front end of the referral pipeline is not being rebuilt.
Prior authorization has become denial by attrition. The appeals exist, the peer-to-peers exist, the published criteria exist — but the cumulative friction is the product. In spine, the delays compound: weeks for the MRI, weeks for the injection series required before the MRI is deemed necessary, weeks for surgical authorization, weeks for the appeal when the first request is denied on documentation rather than clinical grounds. The natural history of a progressive radiculopathy or cervical myelopathy does not pause for utilization review.
Patients feel the symptoms but not the system. They experience the ten-week wait, the denial letter, the requirement to repeat physical therapy they completed two years ago. They do not see that the wait exists partly because their PCP retired, or that their MRI was denied for a missing phrase rather than a clinical disagreement. They blame the front desk, the surgeon, or conclude this is simply how medicine works now. That last conclusion is the most dangerous, because it converts a structural problem into personal resignation.
We can keep optimizing on our end — ASC pathways, navigators, in-house authorization teams, direct access models — and we should. These are necessary and not sufficient. The harder work is naming the system honestly to the people who can change it: patients who can advocate, employers who purchase the plans, and the medical directors who still believe the current friction reflects clinical rigor rather than margin protection.
Awareness on our side, without translation to theirs, is just professional grievance. Translation is the work.
The leaders featured in this article are speaking at Becker’s 23rd Annual Spine, Orthopedic and Pain Management-Driven ASC + The Future of Spine Conference, set for June 11-13, 2026, at the Swissotel Chicago.
At the Becker's 23rd Annual Spine, Orthopedic and Pain Management-Driven ASC + The Future of Spine Conference, taking place June 11-13 in Chicago, spine surgeons, orthopedic leaders and ASC executives will come together to explore minimally invasive techniques, ASC growth strategies and innovations shaping the future of outpatient spine care. Apply for complimentary registration now.
