From block time sitting empty to bundled payments left unbundled, ASC leaders say the gap between what their centers are capable of and the number of procedures they’re actually performing is wider than most will admit.
Thirty-three ASC leaders joined Becker’s to discuss where the industry is leaving opportunity on the table. The answers ranged from underutilized OR flip rooms to untapped value-based care models..
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Editor’s note: Responses have been lightly edited for clarity and length.
Question: What’s one area where you think the ASC industry is leaving opportunity on the table?
Vijay Bachani. President and Chief Growth Officer of New York Bariatric Group (Roslyn Heights, N.Y.): With the popularity of independent dispute resolution, there is an opportunity to get more cases if the ASC is in network with the payers. That’s one of the key components for IDR as case has to be performed at an in-network facility.
Peter Bravos, MD. Chief Medical Officer of Surgery Center Division at Sutter Health (Sacramento, Calif.): AI is no longer on the horizon for ASC operations. Predictive scheduling, coding automation and supply chain optimization are now baseline capabilities. Yet a consequential opportunity remains largely untapped: the intersection of AI and outcomes data. ASCs produce some of the most procedure-specific clinical datasets in healthcare, but too often this data is treated as a compliance requirement rather than a strategic asset.
AI changes that.
Properly applied, ASC outcomes data becomes negotiating leverage with payers, a competitive edge for employers and the foundation for scalable, value-based arrangements that reflect true ASC performance. This is not a question of whether AI will reshape the ASC landscape. It already is. The real question is who will define the benchmarks, and who will be measured against them?
Ray Brown. CEO of Lucien ASC (Maitland, Fla.): I think some players in the industry have to look at their ownership model, and how they allow new surgeons to buy in at a price that is not a barrier to entry, or allow younger surgeons the ability to buy in. I believe to get to a good bottom line, we need to be mindful of our top line revenue.
Lisa Cooper. CEO of Santa Cruz (Calif.) Surgery Center: Cross marketing and education in the lobby: Many centers have a TV monitor in the lobby, but often they are off. We use the opportunity to cross market specialities such as awareness of colon cancer, education on responsible and safe post-operative pain management, etc. We also use the video as an opportunity to introduce staff and physicians without their masks, with bio, photos and names being shown in between videos.
Brian Cunningham, MD. Director of Ambulatory Surgery at TRIA Orthopedics and Vice Chair and Director of Inpatient Orthopedics at Methodist Hospital (Minneapolis): ASCs have a tremendous opportunity to move towards the bright spots. Simple concept, but it can be challenging to execute on. In essence find the people, teams or surgeons excelling then learn what they are doing. What’s different? Shift the mentality from “they are just outliers” to “how do we make this the standard?”
Daniel Decker, MD. Co-Founder of Vitality Plus Urology Clinic (Mountain Home, Ark.): While the numerous applications of AI technologies to lower overhead and increase margins is the trendy pick, ASCs taking the lead in the ultimate CMS target of value-based care transition has vast opportunity that will hopefully not be left on the table.
ASCs (as compared to hospital-based operative systems) thrive on optimizing operational efficiencies, focused patient-centered outcomes, and a tight-knit team approach that could excel in documenting superior surgical care.
Larger hospital-based operative systems tend to inevitably get bogged down with a few disenfranchised team members that will undermine VBC. If structured appropriately, ASCs have the infrastructure and expertise to lead in transforming from fee-for service and idealistically negotiating a fee structure that rewards quality over quantity. The rapidly growing adoption of surgery-focused EMRs at ASCs will enhance and streamline the needed data to validate VBC.
Harel Deutsch, MD. Associate Professor at Rush University and Co-director of Rush Spine Center (Chicago): ASCs are too focused on fusions and big surgeries and are not paying attention to less invasive procedures and possible out-of-pocket procedures/alternative medicine
Jack Dillon. CEO of Anesthesia Practice Consultants (Grand Rapids, Mich.): One of the most underused strategies in the ASC industry is using equity-driven models to intentionally recruit, retain and reload surgical volume through the next generation of independent physicians. As senior, high-volume surgeons slow down, reduce FTEs or approach retirement, many ASCs accept volume attrition rather than actively recruiting emerging surgeons who are seeking autonomy, efficiency and ownership. The opportunity is to deploy structured equity pathways tied to measurable performance — case volume growth, block utilization and contribution margin — while aligning anesthesia, staffing and OR access to accelerate ramp-up. By offering younger surgeons a clear path to ownership and operational influence, ASCs can capture loyalty early, stabilize long-term volume and avoid the costly gap created by retiring partners. In a market where employment often limits physicians’ equity and control, independent ASCs that use ownership as a recruitment and retention tool can preserve independence and build a durable, multi-generational surgical platform with aligned incentives and sustained growth.
Bruce Feldman. Former Administrator of Eastern Orange Ambulatory Surgery Center and Current Founder of an ASC Consulting Firm (Cornwall, N.Y.): The one area where I think the ASC industry is leaving an opportunity on the table is not promoting itself enough to political leaders as to the benefit of what ASCs bring to the table. Promoting the cost savings ASCs can offer over hospitals is crucial in achieving higher reimbursement rates especially given the shift in higher-acuity-level cases moving to the ASC environment.
Nyleen Flores. Administrator and COO of Lake Oconee Orthopedics (Greensboro, Ga.): ASCs are leaving a major opportunity on the table by not treating regulatory compliance as a core, data-driven function — instead of a check-box exercise tied only to surveys. Key gaps include failure to integrate credentialing, privileging, peer review and quality data, leading to missed red flags and increased exposure to CMS citations, litigation, and accreditation risk. Elevating compliance to a central operational strategy — with real-time monitoring, cross-functional data use, and proactive risk identification — can reduce liability while strengthening performance and reputation.
Megan Friedman, DO. Chair and Medical Director, Pacific Coast Anesthesia (Los Angeles): One of the biggest missed opportunities in the ASC space is fully integrating anesthesia into operational decision-making. Anesthesia is often treated as a downstream service, when it actually sits at the center of throughput, staffing efficiency and case flow. When there is misalignment in scheduling, block utilization or coverage models, it shows up as delays, underutilized rooms and avoidable cost. The real opportunity is to involve anesthesia earlier in planning and use real-time data to match staffing with demand. Centers that do this well are not just busier, they run more predictably and with better margins.
Sean Gipson. CEO and Division President of ASCs for Remedy Surgery Centers (Hurst, Texas): One major area where the ASC industry is leaving opportunity on the table is with the underutilization of higher-acuity procedures. ASCs have traditionally focused on low-risk, high-volume cases (e.g., endoscopy, ophthalmology), but advances in anesthesia, minimally invasive techniques, and post-op care now make it possible to safely perform more complex procedures in outpatient settings.
Where the opportunity is being missed:
- Spine procedures (e.g., minimally invasive lumbar surgeries)
- Total joint replacements (hips, knees — now increasingly outpatient-appropriate)
- Cardiovascular procedures (select cath lab and electrophysiology cases)
Hospitals still dominate these higher-revenue procedures, even when ASCs could perform them at lower cost with similar outcomes. Reimbursement models (including CMS approvals of outpatient procedure lists) are increasingly supportive of shifting cases to ASCs. Patients prefer ASCs due to convenience, lower infection risk and faster discharge.
What’s holding ASCs back:
- Physician alignment issues (surgeons tied to hospital systems)
- Capital investment barriers (equipment, robotics, infrastructure)
- Payer contracting limitations
- Risk tolerance; some centers are slow to expand case complexity
Other notable missed opportunities include:
- Ancillary revenue streams (imaging, PT, pharmacy integration)
- Value-based care participation (bundled payments, shared savings)
- Data analytics and operational optimization (many ASCs underuse their data)
- Specialty consolidation (fragmented ownership reduces negotiating power)
George Hanna, MD. President, Director of Pain Management and Chief Transformation Officer at VIP Medical Group’s Vein Clinic and Pain Treatment Center (New York City): One of the biggest areas where ASCs are leaving opportunity on the table is failing to directly confront insurer underpayment and the increasingly anti-competitive tactics used against high-performing independent facilities. Many ASCs still operate defensively within inadequate in-network contracts, despite clear evidence that commercial payers are systematically under-reimbursing procedures relative to cost, while simultaneously inflating patient cost-sharing and misrepresenting true market rates.
At the same time, we’re seeing a concerning pattern of anti-competitive behavior where payers actively penalize ASCs that partner with out-of-network physicians — including contract terminations, reimbursement reductions and administrative barriers designed to steer volume and suppress fair payment. These tactics are less about cost control and more about preserving payer leverage and limiting independent competition.
The opportunity is for ASCs to shift from passive participants to strategic operators — leveraging site-of-care economics, transparency and legal frameworks like the No Surprises Act to demand appropriate reimbursement. Those that do will not only outperform financially, but also help correct a market that is increasingly distorted by anti-competitive insurer behavior.
Aaron Hayes. Administrative Director of North Pointe Surgery Center (Lancaster, Pa.): One area where I believe the ASC industry is leaving meaningful opportunity on the table is in how it approaches vendor strategy. As more procedures continue to migrate into the ASC setting, both case volume and case complexity are increasing. However, many centers are still operating under legacy pricing structures and vendor arrangements that were established under very different volume assumptions.
This issue extends well beyond implant pricing alone. It includes primary material distributors such as Medline and McKesson, implant and disposable vendors like DePuy, Arthrex, Smith & Nephew, and Stryker, as well as ancillary services such as linen and scrub providers. It also applies to third-party operational vendors including payroll systems, clearinghouses, revenue cycle management partners and IT services.
Part of the challenge is structural. ASC administrators and leadership teams are often wearing multiple hats across clinical, operational, and financial responsibilities. Unlike large health systems that have dedicated teams focused on supply chain, procurement, and vendor management, ASC leaders are balancing a wide range of priorities. As a result, vendor strategy can easily become a periodic task rather than a continuous focus.
Rather than treating vendor contracting as a periodic renegotiation exercise, there is a significant opportunity to shift toward a more dynamic and data-driven approach. This includes regularly benchmarking pricing against the market, aligning physician utilization to support standardization where clinically appropriate, and maintaining consistent competitive pressure among vendors across all categories.
If organizations are not actively demonstrating that they are evaluating the market and holding vendors accountable for both price and service, there is little incentive for those vendors to improve terms. Vendors will not proactively offer better pricing or service without pressure. In many cases, vendors benefit from ASC growth more than the centers themselves.
A more disciplined and comprehensive approach to vendor management can materially improve margins while supporting continued growth in higher-acuity procedures.
Krishna Jain, MD. CEO of National Surgical Ventures and Limb Preservation Centers of America: There are many cardiovascular ASC openings in the country. Many of these ASCs are not including management of peripheral arterial disease in the ASC. ASCs that do offer management of PAD should add wound care centers to offer limb preservation as an offering. This addition increases revenue significantly and improves care.
Les Jebson. Administrator of Prisma Health’s Orthopedics & Sports Medicine Institute (Columbia, S.C.): As the industry moves toward higher-acuity, complex procedures (e.g., total joints, cardiology), the margin for error shrinks. Proactive investments in clinical and clerical artificial intelligence integrated solutions are no longer optional to not incorporate to ensure sustained profitability. The challenge resides in which AI solutions possess realistic ROIs and can measurably enhance — not disrupt — workflows.
Earl Kilbride, MD. Orthopedic Surgeon at Austin (Texas) Orthopedic Institute: One area that often can make or break an ASC is contracting. It is not just good or bad contracts that can affect things but having an administrator who is thoroughly familiar with each contract and its intricacies is vital to the ASC’s bottom line. Many of the contracts, including Medicare, don’t include the cost of implants. Knowing where and what to watch can really be a valuable asset to the financials.
Scott Kulstad. CEO of St. Paul (Minn.) Eye Clinic: We need to capture value from unused capacity by systematizing OR efficiency — on-time first cases, reliable turnover and disciplined block utilization. A surprising amount of ASC margin is left on the table in the form of minutes: late starts, variable room turnover and underused blocks that could support incremental cases, new service lines or carefully selected partner surgeons. This is operational discipline as strategy — not a “housekeeping” project or surgeon satisfaction strategy. The opportunity is to manage time like inventory: standard work, visible readiness metrics, surgeon-level feedback loops and clear rules for releasing and backfilling time without disrupting core schedules.
Jessica Lam, PhD. Practice Manager of Pacific Coast Anesthesia (Los Angeles): Overall, the strengths of healthy ASCs tend to be efficiency in superior patient outcomes/satisfaction with lowered costs and is perfectly positioned to lead the way for early adoption of value-based care. Like site neutrality on the inevitable horizon, ASCs have a similar golden opportunity to embrace and lead on VBC or react and cling to fragile margins.
Benjamin Levy III, MD. Gastroenterologist at University of Chicago Medicine: Nationally, we should help ASCs increase the number of colonoscopy procedures performed each week. With the recent guideline changes lowering the recommended age for colorectal cancer screening to 45, approximately 21 million new patients require screening — ideally through colonoscopies. This is especially important as early-onset colorectal cancer rates are rising and just became the No. 1 cause of cancer death in patients younger than age 50. Most colorectal cancers are preventable through colonoscopies by removing polyps before they can turn into a cancer. According to a recent 2026 study published in the Journal of the National Cancer Institute, only 22.5% of respondents aged 45-49 had initiated colorectal cancer testing since the USPSTF updated its recommendations. In addition, only 67% of Americans (all eligible ages) nationally are up to date on colorectal cancer screening. We should increase the number of gastroenterologists nationally through training programs. In addition, we should increase the number of available gastroenterology rooms at ASCs to dramatically boost colonoscopy screening rates in America. It’s important for us to educate Americans about the importance of colonoscopies through programs such as the American College of Gastroenterology’s Tune It Up: A Concert To Raise Colorectal Cancer Awareness and TV ad campaigns.
Justin Marburger. Regional Surgical Director of Maximus Plastic Surgery Center and Chrysalis Cosmetic Surgery Center (San Antonio): I believe the ASC industry is leaving opportunity on the table by treating compliance as a requirement instead of using it as a blueprint for operational excellence. The ASC landscape is changing: Hospitals are acquiring ASCs, private equity is consolidating, payers are demanding more data and patients expect better experience. The centers that win won’t just be compliant, they’ll be operationally elite.
Carrie Marut. Administrator of Mentor (Ohio) Surgery Center: One area that I am not sure many ASCs are doing a deep dive on is their custom packs. Meeting with your vendor can be profitable to the ASC, especially with the increase in tariffed items in the packs. We recently met with our vendor and made some adjustments with changing items in the pack or removing, even adding items to a pack we were able to reduce the cost of the pack. After reviewing all packs and making adjustments we calculated a $100,000 savings annually.
Jacquie Mateja, BSN, RN. Clinical Director of Creekside Surgery Center (Anchorage, Alaska): In my experience, underutilization of block time is an area of potentially lost opportunity. Late releasing of blocks and generally unused blocks contributes to wasted hours within all areas of the center. This can lead to staffing issues with the potential need for mandatory over staffing due to low case volume. Fluctuations between too many and not enough staff lead to workforce instability with poor workforce optimization. Strict block release policies should be generated and followed to not only increase potential revenue by allowing other surgeons to fill unused time but to also improve patient access to healthcare. Integrating AI-assisted and data driven scheduling is a way to decrease idle time and ensure that blocks are being filled. Open communication about scheduling trends, scheduling accuracy and open block time with the surgeons and their teams is paramount to decreasing idle time and increasing productivity.
Luke Mitchell. Executive Director of Prevea Health (Green Bay, Wis.): One area I think the ASC industry is leaving a lot of opportunity on the table is site of care migration, especially in orthopedics. We have made progress, but we still are nowhere near where we should be. There is a pretty large gap between what we can safely do in an ASC today and what is actually being done. Total joints, spine and other higher acuity cases are still lagging more than they should. A lot of that comes down to payer policies, misaligned incentives, and honestly, some internal resistance. At the same time, I think we undersell ourselves as an industry. ASCs are not just a lower cost option, but in many cases, they are a better setting for patients. More efficient, more predictable, and often a better overall experience. The systems that really lean into this, aligning physicians, effectively directing care pathways, and pushing the appropriate migration, are going to separate themselves pretty quickly if they have not already.
Monina Pascua. Managing Partner and Quality Chair at the Oregon Clinic (Portland): Investment in robotic surgery is one opportunity the ASC industry is currently leaving on the table. However, this may be changing in some areas. While robotic surgery can often be longer, they can have lower complication rates/shorter recovery and be done in low risk patients making them suitable candidates for the ASC. I think along with this, robotic surgery can lend itself to value-based care opportunities for the ASC industry.
Randy Robbins, MD. President of Valiant Anesthesia Associates (Addison, Texas): One of the places that ASCs are leaving significant revenue on the table is utilizing flip rooms for cases that take 90+ minutes. If a room is sitting empty multiple times a day for over an hour, that room could be utilized to recruit new surgical volume or allow current providers to use the room more effectively. I know that many surgeons are now demanding the second flip room, but the lost revenue could be significant.
Jacob Rodman. CEO of Raleigh (N.C.) Surgical: The ASC industry is under-leveraging bundled payment models. There’s a significant opportunity to align surgeons, anesthesia, implants and post-acute care under a single episode-based structure that drives both cost efficiency and measurable outcomes. Most centers are still operating in fragmented, fee-for-service silos, which limits their ability to control total cost of care and demonstrate value to payers. ASCs that move early to build true bundles — with aligned incentives, standardized pathways and data to prove outcomes — will be far better positioned in payer negotiations and long-term network inclusion.
Greg Schooler. COO of Cincinnati GI: Direct contracting with employers has been mostly overlooked by independent ASCs. We have been very successful in contracting with large, national companies that have offices situated in our service area. We can offer bundled pricing including the facility fee, professional fee, pathology and anesthesia. Our services are extremely cost competitive compared to the local hospitals, our care is more conveniently delivered, and the employer gets immediate and direct feedback from their employee about the quality of care they experienced.
Nirav Shah, MD. President of DDA Division and Chief Medical Officer of Clinical Research for U.S. Digestive Health (Wyomissing, Pa.): Many ASCs still operate with fragmented analytics and wide variation in the devices and accessories gastroenterologists use. This is often driven by preference rather than value. By consolidating commonly used GI devices and accessories coupled with pairing that with quality and outcomes data, ASCs can reduce cost, simplify workflows and improve consistency — while still maintaining physician engagement. This standardization can help unlock meaningful margin and scalability. ASCs also tend to leave value on the table by allowing underutilized block time, late starts and fragmented scheduling that keeps rooms open longer than necessary. By actively managing block release policies, consolidating cases into fewer rooms, and sequencing schedules to end rooms earlier in the day, ASCs can materially reduce overtime, agency labor and staffing inefficiencies.
Syed Shah, MD. Medical Director of Stony Brook (N.Y.) Ambulatory Surgery Center: One area where, in my experience, the ASC industry is leaving opportunity on the table is in the tendency to make centers overly generalized. Having multiple surgical specialties operating within the same ASC can place significant strain on staff and equipment needs. When teams are not specialized for each service line, it may impact efficiency and throughput, and surgeons and proceduralists may not have an optimal experience. An important opportunity lies in developing more specialty focused ASCs. This approach should be guided by a robust, data driven analysis to determine which cases are best suited for the ASC setting, maximizing throughput while also optimizing financial performance. Ultimately, this model has the potential to enhance operational efficiency, improve patient safety and elevate the overall patient experience.
Tammy Smittle, RN. CEO of Stonegate Surgery Center (Austin, Texas): ASCs are leaving significant revenue unrealized by failing to educate physicians on the specifics of their payer contracts. When surgeons are equipped with clear visibility into reimbursement structures and implant costs, they are far more likely to align case selection and clinical decisions with financial sustainability. In practice, many surgeons lack insight into both implant pricing and contracted rates. Yet given their inherently competitive nature, they are highly motivated to avoid unprofitable procedures once that information is transparent.
Sherman Tran, MD. Spine & Sports Medical Group (Campbell, Calif.): One area where I think the ASC industry is still leaving real opportunity on the table is true case level cost visibility. Not just billing or high level supply totals, but a clear understanding of what each individual case actually costs from start to finish. Most centers can tell you what they were reimbursed and give a rough idea of supply spend, but very few can break down the full cost of a case in a way that drives better decisions. That gap matters even more now as reimbursement tightens while labor and supply costs continue to rise.
As a result, many decisions are still based on averages or habits rather than data. Two surgeons can perform the same procedure with meaningful cost differences, yet it often goes unnoticed. When you do have that visibility, it changes behavior. It becomes easier to standardize preference cards, reduce waste, and have more productive conversations with surgeons and vendors, grounded in objective data instead of opinion.
The challenge has always been capturing this data without adding friction. It relies on manual input, incomplete documentation, and disconnected systems, so most centers settle for what is “good enough.” That is exactly where the opportunity sits, especially as newer technologies allow for more passive data capture in the OR.
At our surgery center, we are addressing this by using AI to capture and structure case level data without disrupting workflow. The system is now deployed in three of our centers and is about 95% built out and functional. It is already giving us a clearer view of true cost per case and starting to change how we approach efficiency and decision making.
ASCs have largely optimized throughput and staffing. The next level of margin improvement will come from precision, understanding exactly where money is made or lost on each case and acting on it consistently.
Jessica Welsh. CEO of Surgical Institute of Reading (Pa.): I would say that most ASCs are not truly leveraging the patient experience. Patients love ASCs, but most centers are focused on day-to-day operations and not the bigger picture of using patient experience platforms and other digital marketing tools to turn first-time patients into brand ambassadors. These tools, like social media marketing, paid advertising campaigns on sites like Google, and reputation management can help boost referrals, expand reach and improve case and payer mix.
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