From fragmented data systems to labor schedules built on guesswork, ASC leaders say the gap between what their centers cost to run and what payers are willing to reimburse is quietly becoming an existential threat.
Six ASC leaders joined Becker’s to discuss the industry’s most stubborn unsolved problems. The answers ranged from predictive staffing blind spots to a reimbursement model that treats anesthesia like a line item instead of a foundation.
Editor’s note: Responses have been edited lightly for clarity and length.
Question: What is one problem in the ASC industry that no one has solved yet?
Stephanie Conquest. Administrator of Vanderbilt Surgery Center Cool Springs (Franklin, Tenn.): One unsolved problem in the ASC industry is aligning site of care with patient acuity to truly optimize value. Lower-risk, clinically optimized patients should be treated in ASCs, while higher-acuity patients belong in hospital outpatient departments — but this is not happening consistently.
Despite ASCs delivering high-quality, lower-cost care, hospitals still receive higher reimbursement and often control referral pathways, steering cases to HOPDs without fully considering acuity or system-wide value. While CMS has expanded the ASC-approved procedure list, the industry has yet to solve for a coordinated, value-based approach that aligns incentives across providers and settings.
Scott Freer. Clinical Administrator of ASC Bala Cynwyd (Pa.): The biggest unsolved problem in the ASC industry is predictive labor optimization at the case level. Here’s what that means: ASCs live and die by their OR schedule, but virtually every staffing decision is still made reactively — built around block schedules and historical averages rather than real-time or predictive case demand. No one has cracked the code on a system that accurately predicts, day by day and room by room, exactly how many scrub techs, circulating nurses, and PACU staff you’ll need — and then dynamically adjusts labor commitments before the day starts.
The core problem has a few layers to it:
- Case mix unpredictability. A spine case and a cataract case can be scheduled in the same block but require completely different staffing profiles. Surgeons add cases, cancel cases, and run long — and no scheduling software today accounts for that variability in a way that feeds back into labor planning.
- The fixed versus variable cost trap. ASCs staff to their worst-case scenario because they can’t predict well enough to staff to their actual scenario. That gap — between worst-case staffing and actual case volume — is where tens of thousands of dollars disappear every year, per facility.
- No clean data layer. ASCs often run on fragmented systems — one platform for scheduling, another for HR, another for billing — that don’t talk to each other. Without integrated data, any predictive model is flying blind.
- Agency and PRN labor without intelligence. Facilities either over-rely on expensive agency staff or under-use them, because there’s no system that tells you when to activate flex labor before you’re already short-staffed on the day of surgery.
Some EMR and workforce management vendors are gesturing at this problem, but nobody has built a purpose-built, ASC-specific labor intelligence layer that closes the loop between the OR schedule and the staffing plan in real time. The facilities that figure out even a rough version of this — like a [post-anesthesia care unit/preadmission testing/pre-operative assessment/compliance] hybrid model — generate enormous savings.
Megan Friedman, DO. Chair and Medical Director of Pacific Coast Anesthesia Consultants (Los Angeles): The biggest unsolved problem is the misalignment between anesthesia coverage expectations and reimbursement models. ASCs expect reliable, all-day anesthesia coverage regardless of fluctuations in case volume, but payment is still largely tied to per-case or per-unit production. That mismatch creates a structural gap where anesthesia is operationally essential but financially undervalued. Until there is a consistent model that recognizes anesthesia as a fixed coverage requirement rather than an à la carte service, this tension will persist.
Bonnie Greenblatt. Director of Ambulatory Surgical Services of Michigan Institute of Urology (Utica): The ASC industry still lacks a standardized, transparent reimbursement model- leaving centers to navigate inconsistent payor rules, administrative overload, and unpredictable revenue. Despite efforts to streamline, we still function in a highly complex and ever-shifting reimbursement landscape.
Tracy Hoeft-Hoffman, RN. Administrator at Heartland Surgery Center (Kearney, Neb.): One of the biggest challenges the ASC industry has not yet solved is how to sustainably grow in an environment where costs are rising faster than reimbursement. ASCs are increasingly being asked to take on more complex procedures, invest in advanced technology, and meet expanding regulatory and quality expectations. At the same time, reimbursement — particularly from commercial payers — has not consistently kept pace with those demands.
The ASC model is built on efficiency and high-value care, and we continue to deliver on that promise. However, there is a real tension between innovation and financial sustainability. Without more aligned reimbursement structures, there is a limit to how far ASCs can continue to expand access, adopt new technologies, and absorb higher-acuity cases. If we want ASCs to play a larger role in the future of healthcare delivery, payment models will need to evolve alongside the care we are already providing.
Neeraja Kikkeri. Owner and CFO at North Texas Team Care Surgery Center (Mesquite): Greed. Greed from anesthesia and insurance companies. Everyone wants to earn money but when you cannot get viable payment for services then we have a huge problem that is only getting compounded every year. Shrinking revenue does not translate to increasing stipends from anesthesia.
Michael Warne. CEO of Associated Gastroenterologists of Central New York (Camillus): I’ll skip the low-hanging fruit on anesthesia. I’m sure it’s been talked to death, as it should be. My answer: payer reimbursement. ASCs deliver the same procedures at a fraction of the hospital cost, and payers know it, yet reimbursement rates have lagged so far behind inflation and operational reality that the math is becoming unsustainable. We are subsidizing payer margins with our efficiency. Until there is real pressure on payers to close that gap, ASCs will keep doing more with less while the people benefiting most from that arrangement pay the least for it.
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.
