As health system employment loses its luster, squeezed by shifting RVU targets, limited autonomy and burnout, a growing number of surgeons are leaving ASCs for a workplace shift.
Janet Carlson has seen it play out across her career as an ASC leader, and now, as founder of her own consulting firm, Vertex Surgical Solutions. For physicians willing to ask the right questions, she told Becker’s, an equity stake in an ASC may be the most consequential financial move they ever make.
“The odds are that pursuing and purchasing an equity stake in an ASC would be one of the best financial decisions they’ve ever made in their lives,” Ms. Carlson said. “If they have the opportunity and they know the right questions to ask, it could already be a very successful business to buy into — albeit potentially costly.”
The average physician compensation in a solo practice was $457,562, according to Doximity’s “2025 Physician Compensation Report.” This was the third highest-earning employment setting for physicians in the survey, trailing behind only single-specialty and multispecialty group practice.
For surgeons entering the market, there are two primary paths, Ms. Carlson said. The first is buying into an established, profitable ASC, a lower-risk entry that comes with an existing patient base and operational infrastructure. The second is joining a de novo project at the ground floor, helping shape everything from clinical protocols to the patient experience.
“I always recommend to any surgeon who asks my opinion that buying into a de novo ASC is probably one of the best lottery tickets you’ll ever find,” she said.
Beyond the financial upside, Ms. Carlson argues that ASCs simply deliver a better environment for patients and physicians.
She describes the ASC model as offering patients a “concierge, bespoke experience,” backed by infection rates that consistently outperform hospital settings. The operational consistency of a tight-knit ASC team, she said, is a direct driver of that quality.
“You have the same people working every day in your ASC ORs,” she said. “You know one another, you know the surgeons, you know the workflow — and all of that adds to patient safety.”
At a typical hospital OR, there are locum tenens staff cycling through, high turnover and slow room turnovers that eat into a surgeon’s schedule and patience. For physicians accustomed to moving efficiently through a case list, the friction compounds quickly.
That operational frustration is accelerating a broader reckoning with physician employment, one Ms. Carlson says has been building since the pandemic.
“I still maintain we haven’t recovered from COVID,” she said. “The long-term sequelae are people looking at quality of life, work-life integration, and autonomy. It’s difficult to achieve those things when you’re employed in a health system.”
The data backs this up. According to a survey from consulting firm Bain & Co., average satisfaction for physician-led organizations ranges from roughly 70% to 90%, compared to 50% to 75% in health system-led practices. Nearly 25% of surveyed physicians in health system-led organizations said they were contemplating a change in employers, compared to just 14% in physician-led practices, according to the Bain survey. Notably, of those considering a switch, 37% were looking to move to physician-owned settings.
The appeal of employment is understandable, with a guaranteed salary, malpractice coverage and administrative support. But Ms. Carlson said that appeal increasingly doesn’t hold up under scrutiny. Employed physicians, she said, often have little autonomy and limited leverage when it comes to compensation negotiations.
Additionally, the RVU model, the standard productivity metric for most employed physicians, has become a particular flashpoint.
“They end up with an RVU structure that becomes a moving target,” Ms. Carlson said. “The health system changes the metrics constantly or dilutes their referral pool, and that drives heightened dissatisfaction.”
The result is a wave of surgeons reconsidering their options — looking toward independent practice, multispecialty organizations, and ASC ownership as viable alternatives to the health system track.
“A lot of surgeons are considering leaving health system employment and looking for opportunities to go independent or join an independent MSO — a multispecialty practice where they can hang out their own shingle,” Ms. Carlson said. “Physicians get frustrated by limited block time and the inefficiency compared to an ASC. They want to tackle their patient surgery list and move forward.”
What’s notable, she said, is that this isn’t just a phenomenon among mid-career physicians who’ve grown disillusioned. Younger surgeons, some fresh out of fellowship, are also opting out of the employed model before they’ve fully settled into it.
“We’re even seeing this with younger surgeons, newly out of fellowship, who have left health systems to strike out on their own,” Ms. Carlson said. “I really admire that.”
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