ASCs have become a cornerstone in the healthcare landscape — offering patients a cost-effective and efficient alternative to traditional hospital settings for various surgical procedures — but barriers remain.
Here are three things weighing onASC growth:
Certificate-of-need laws
Certificate-of-need laws, which regulate the establishment and expansion of healthcare facilities, are designed to control costs and prevent unnecessary duplication of services. However, many ASC leaders argue that they stifle competition and hinder access to care.
Brett Maxfield, CRNA, president and CEO of Maxfield Healthcare Solutions and president of the Idaho ASC Association, told Becker's that the biggest obstacle to ASC growth is certificate of need laws.
"In many states, it blocks the ability to create new surgery centers, often due to political and financial motives," he said.
Other leaders echo these thoughts, particularly in specialties like cardiology.
The rapid development of technology for cardiac procedures has outpaced updates to regulation in some states, Danielle Martin, an administrator and director of physician services at Richmond-based Virginia Cardiovascular Specialists told Becker's.
"One of the biggest challenges that we experienced when we were doing the CON was the fact that the state manual for the CON for a cath lab was written, in the '80s or '90s, many years ago, when outpatient cath labs were just not a thing," Ms. Martin said. "[The law] didn't really address the needs of having an outpatient cath lab and all the wonderful things that go into an ASC offering a quality place for people to come and have their procedures. The state did recognize that there was a need for our area to have that option out there for our population. But that was definitely a big hurdle that we had to overcome."
Nashville, Tenn.-based HCA Healthcare faces challenges expanding its ASC network in states with certificate-of-need laws, CFO Mike Marks said during the health system's Jan. 24 earnings call. Mr. Marks noted that HCA can expand its outpatient network "much more quickly and aggressively" in states without CON laws. By contrast, regulations in states such as Georgia, Virginia and North Carolina create barriers that slow or limit the company's ability to develop new ASCs.
Reimbursements
Reimbursement is another challenge, Mr. Maxfield said, citing both overall reimbursement rates and reimbursement for specific equipment like implants.
"In some cases, the reimbursement doesn’t cover the cost of implants, let alone the surgery," he said. "Those cases often have to go to hospitals, which are better reimbursed. Unfortunately, the patient bears the financial burden, which is a significant issue."
Patients end up paying more money with this discrepancy, he said, "due to policies and reimbursement structures, which is a systemic issue influenced by government and insurance practices."
Additionally, ASCs are struggling to meet margins as procedures continue to migrate to the outpatient setting but reimbursements stagnate. Although CMS finalized a reimbursement increase of 2.9% for ASCs meeting quality reporting requirements in its 2025 final rule for Medicare payments to hospitals and ASCs, many leaders worry it won't be enough to offset rising costs.
"Everything is getting more expensive — supply costs, practice costs, salaries for employees, et cetera — but insurance companies don't want to pay anymore, so margins are very, very thin," April Aud, RN, BSN, the administrator of Black River Ambulatory Surgery Center in Poplar Bluff, Mo., told Becker's. "I worry that eventually, small ASCs in small towns or markets are not going to be able to make it because they can't afford it. Especially because these smaller ASCs often have a lot of Medicare patients, the reimbursement there is not sufficient and there's a limited number of commercial patients. I worry that a lot of small ASCs that serve communities that really need the ASCs in the area are not going to be able to survive. And as bad as it is to talk about the monetary side of it, you have to."
Lack of education
A significant barrier to ASC growth is the lack of understanding among policymakers regarding the reimbursement system. Educating decision-makers can lead to meaningful policy changes. Advocacy from ASC organizations plays a crucial role in this regard. The Ambulatory Surgery Center Association, for instance, is actively pushing for better ASC reimbursements at the federal level.
"Many politicians making healthcare decisions don't fully understand the reimbursement system," Mr. Maxfield said. "Educating these decision-makers can lead to meaningful policy changes."