By Don Sadler
More and more patients today are choosing ambulatory surgery centers (ASCs) over traditional hospitals for their surgical procedures. ASC surgical volume is expected to increase by 21% over the next decade to reach 44 million procedures a year by 2034.
The migration of total joint procedures is one noteworthy trend in the ASC surge. According to the 11th Annual Report from the American Academy of Orthopaedic Surgeons (AAOS), released in November 2024, ASCs performed 62,110 total joint procedures in 2023, a 70% increase over the year before. More than half of joint replacements will be performed on an outpatient basis by 2026, the AAOS projects.
“This surge reflects the growing role of ASCs in delivering joint arthroplasty care across the U.S.,” says Jeanine Watson, MSN, RN, CNOR(E), CASC, senior manager, ASC Division of the Association of periOperative Registered Nurses (AORN.).
“The ASC setting is becoming the preferred site for orthopedic and joint replacement care, especially for lower-risk patients,” says Raghu Reddy, MBA, BS, CMR, chief administrative officer of MiOrtho Surgery Center in Southfield, Michigan, and Ambulatory Surgery Center Association (ASCA) board member. “I believe this trend will likely accelerate as technologies and protocols continue to improve.”
A Safe and Efficient Alternative
Why the surge in procedures performed at ASCs? In short, ASCs offer a safe, efficient and cost-effective alternative to inpatient hospital surgery for appropriate cases.
“ASCs offer high-quality care with excellent outcomes, lower costs for both patients and payers, more efficient scheduling, and an overall enhanced experience,” says Watson.
“Ambulatory surgery centers continue to play a vital role in expanding access to safe, high-quality surgical care,” says Noel Adachi, president and CEO of the Accreditation Association for Ambulatory Health Care (AAAHC). “Even as ASCs navigate rising costs, workforce shortages and evolving safety expectations, their commitment to excellence remains unwavering.”
“Patients are increasingly opting for ASCs due to their lower costs, reduced wait times and more personalized care environments,” says Reddy. “At the same time, payers are actively encouraging ASC utilization for healthier, lower-risk patient populations due to significant cost savings and efficiency gains. Together, these forces are driving sustained ASC growth and reshaping the surgical care delivery landscape.”
Jason Weshler, MSc., MBA, vice president, outpatient solutions with Siemens Healthineers North America, believes that rapid ASC growth is bringing opportunity while helping improve the overall patient experience.
“ASCs are by necessity driving efficiencies,” says Weshler. “For example, ASC capacity is growing through the addition of operating rooms as opposed to new ASC facilities. We also continue to see clinicians designing new facilities to accommodate multiple specialties in the same operating rooms.”
ASC Challenges
Whether through increased volume or the addition of new service lines, the ASC surge is presenting a number of challenges that impact every aspect of facilities. Reddy calls the rapid growth of ASCs “a double-edged sword. While it’s exciting to see expansion, many centers might lack the necessary resources to scale effectively. Once a facility is built based on a specific pro forma and reaches its capacity, it becomes constrained by those original limitations.”
Watson says that introducing new procedures often requires substantial investments in capital equipment, specialty supplies, surgical instruments and patient positioning devices. “These additions can strain existing storage capacity and require thoughtful planning to avoid space constraints.”
Jamie L. Ridout, RN, MSN, MBA, NEA-BC, CNOR, CASC agrees.
“One challenge for ASCs is being able to afford and secure high-dollar capital such as robots for total joint procedures,” she says. “Patients have choices in where they elect to go for their surgery. For ASCs to thrive in competitive markets, they must offer the same or better technology than their competition.”
Weshler says he is seeing strong interest among ASCs in adding new service lines like cardiology. “But these come with added complexity, such as specialized equipment, state-level regulatory hurdles and evolving reimbursement dynamics. The move toward site-neutral payments, coupled with insurance variability and advances in technology, will continue to challenge ASC scalability.”
Staffing Stress
Staffing remains one of the biggest challenges ASCs face in the midst of the surge.
“ASCs often find themselves competing with large hospital systems that can offer higher salaries and more comprehensive benefits packages,” says Watson. “Due to typically lower profit margins, ASCs may not be able to match these financial incentives.”
Weshler says that staffing is especially challenging for new ASCs that are still ramping up volume and not yet operating at full capacity.
“ASCs are increasingly seeking staff from other specialties, such as radiologic technologists, to support more complex procedures,” he says.
In addition, some ASCs are stressing advantages such as more consistent schedules and better work-life balance.
“These can be a strong draw for many clinicians and nurses,” says Weshler.
According to Reddy, the ASC industry has lost a significant portion of its experienced workforce to retirement and career changes.
“Recruiting skilled personnel has become increasingly difficult and retaining them is even more challenging amid wage competition driven by ongoing staff shortages and inflation,” he says.
Watson recommends that ASCs focus on the advantages they can offer staff in comparison to hospitals.
“These include offering more favorable schedules – such as no weekend, holiday or on-call shifts – along with a more predictable and efficient work environment,” she says.
Higher Costs Pose Long-Term Risks
Higher costs are another challenge faced by ASCs. “Rising costs and shrinking reimbursements are shaking the ASC industry and the issue remains largely unaddressed, posing significant long-term risks,” says Reddy.
“Cost pressures continue to rise for ASCs at every stage of the operation,” says Weshler. “From the initial facility design and construction, where materials and labor costs have surged, to technology integration and day-to-day operations, expenses are increasing across the board.”
To manage cost pressures, Weshler says that many ASC leaders are becoming more selective and strategic about technology investments. “In some cases, this means choosing equipment configurations or consumables that are scaled appropriately for the ASC environment rather than mirroring hospital-level technologies. We’re also seeing a stronger emphasis on collaboration and shared services to help control costs.”
Anesthesia costs are a particular concern for ASCs.
“Many ASC leaders report that anesthesia groups are now requiring minimum case volumes and if those thresholds aren’t met, the ASC must cover the financial shortfall,” says Watson. “And temporary anesthesia providers are costly and increasingly difficult to secure.”
To address anesthesia cost challenges, some ASCs are revisiting the use of nurse-administered moderate sedation for select procedures.
“While this approach can help mitigate anesthesia shortages, it introduces new requirements,” says Watson. “Two nurses must be present per procedure and specialized training and certification are necessary to ensure safety and compliance.”
“Declining anesthesia reimbursements have placed substantial financial pressure on ASCs, often requiring facilities to provide subsidies just to maintain anesthesia coverage,” says Reddy. “Although several anesthesia models have evolved in response, the underlying burden persists unless reimbursement challenges are addressed through legislative actions.”
Ridout agrees: “While there may be creative strategies to support our anesthesia partners, I believe the solution runs much deeper and involves more intensive efforts to lobby for public policy addressing fair and equitable reimbursement structures and conversion factors for anesthesia coverage.”
Medicare Payment Rates
Perhaps the biggest financial challenges faced by ASCs today are cost pressures related to Medicare payment rates, especially through the ASC Quality Reporting (ASCQR) Program.
“To receive the full annual payment update, ASCs must submit quality data for standardized measures,” explains Watson. “Failure to meet these reporting requirements can result in a two-percentage point reduction in the annual payment update.”
However, accessing the Centers for Medicare and Medicaid Services (CMS) reporting platform is complex and time-consuming, Watson says. “This can delay or complicate timely data submission.”
To avoid penalties, Watson encourages ASC leaders to stay informed about reporting deadlines and requirements, ensure proper staff training and establish internal processes that support accurate and timely data collection.
“Proactive planning and oversight are key to maintaining reimbursement levels and supporting financial sustainability,” she says.
“CMS payment updates continue to lag behind inflation and fail to keep pace with rising wages, anesthesia staffing costs and the increasing prices of supplies and equipment,” says Reddy. “Anesthesia reimbursement remains at historically low levels, which creates significant challenges for centers serving a large Medicare population.
“While many ASCs are attempting to reduce expenses, there’s only so much cost-cutting that can be done without compromising quality of care,” Reddy adds.
Ridout says that industry organizations are fighting for parity in reimbursements for procedures that can be appropriately and safely performed in an ambulatory surgery center. “ASCs can assist in this by continually demonstrating a lower cost of care with the same or better-quality outcomes for patients. Continually making the argument that patients ultimately pay less when receiving their care in an ASC should be an attractive factor for payors.”
Prioritizing Safety & High-Quality Care
ASCs have long prioritized patient and staff safety by consistently delivering high-quality care in a controlled and secure environment. “Traditionally, these safety efforts focused on preventing infections, minimizing complications and ensuring readiness for clinical emergencies,” says Watson. “In recent years, safety protocols have evolved to address broader concerns, including facility and environmental security.”
Accreditation bodies now require ASCs to implement policies addressing workplace violence and provide staff training on this issue. “Many centers have also begun conducting active shooter drills and enhancing physical security measures to ensure preparedness for a wider range of potential threats,” says Watson.
According to Reddy, ASCs have consistently demonstrated a strong record of safety.
“The data continues to support this,” he says. “Numerous studies and patient surveys demonstrate that ASCs provide safe and effective care, beginning with stringent patient selection criteria to ensure each case is appropriate for the ambulatory surgery setting.”
AAAHC maintains a dedicated safety category within its accreditation standards that outlines clear expectations designed to prevent injury and illness and minimize risks to patients, staff and visitors. “These standards emphasize the importance of a proactive safety culture that identifies, assesses and mitigates risk before harm occurs,” says Adachi.
An effective safety program includes comprehensive risk assessment processes; mechanisms for reporting and managing hazards, near misses and other safety concerns; and oversight by the governing body. “Incorporating preventive measures and ongoing evaluation helps organizations prioritize high-risk areas and sustain safe, reliable care environments,” says Adachi.
“AAAHC continuously strengthens its standards by engaging a wide range of stakeholders across the health care community,” Adachi adds. “Our standards remain peer-reviewed, evidence-based and reflective of evolving best practices across diverse ambulatory specialties and settings.”
AAAHC offers a wide range of tools and solutions designed to help ASCs address challenges and “maintain continuous survey readiness throughout the 1,095-day accreditation cycle,” says Adachi. These include:
1095 Engage resources: This suite of readiness tools within the Help Curtain of the 1095 Engage platform includes the Self-Assessment Tool, which enables organizations to evaluate their performance against current AAAHC Standards.
Achieving Accreditation program: This interactive, immersive event helps organizations prepare for their onsite survey and deepen understanding of AAAHC Standards through peer discussion and faculty-led sessions.
1095 Learn eLearning modules: AAAHC’s on-demand learning portal offers a comprehensive curriculum that guides organizations through every step of the 1095 Strong journey to support continuous quality improvement and readiness.
The AAAHC Institute for Quality Improvement (IQI): In addition to the Quality Roadmap, IQI provides practical toolkits and data-driven insights addressing common survey findings, standards interpretation and quality improvement best practices.
IQI Benchmarking Studies: These studies enable organizations to measure and compare performance across peers, meet AAAHC benchmarking requirements and drive targeted, evidence-based improvements.
“Together, these resources reinforce AAAHC’s commitment to supporting ambulatory organizations in achieving excellence in quality, safety and patient care,” says Adachi.
An Evolving Landscape
Weshler believes that the ASC landscape will continue to evolve rapidly – and with this evolution comes more opportunity. “Organizations that plan proactively, form strategic partnerships and design flexibility into their facilities will be best positioned to adapt and take advantage of new growth opportunities as they arise.”
