Session: Hoisting the Sails—Winning Strategies for Growing Service Lines in an ASC

Editor's Note

In this session, Deb Yoder, MHA, BSN, RN, CNOR, CASC, vice president of facility development, Compass Surgery Partners, provided a comprehensive overview of selecting, implementing, and managing service lines in ambulatory surgery centers (ASCs) while considering factors such as block time utilization, staff readiness, equipment needs, financial viability, and facility infrastructure. Key insights were shared on high-margin specialties like orthopedics and cardiovascular procedures, as well as the financial pitfalls of poorly planned expansions.

Some insights on understanding ASC growth and service line selection include:

• Hospitals are increasingly converting hospital outpatient departments (HOPDs) into freestanding ASCs due to insurer pressure to eliminate higher HOPD reimbursement rates.
• Service line expansion requires careful consideration of available OR block time, surgeon demand and scheduling accuracy, staff expertise and willingness to train in new specialties, existing facility infrastructure and necessary upgrades, and financial feasibility and return on investment.
• To maximize OR utilization and block time efficiency—
  • track block time usage with data (surgeons often overestimate how frequently they use their scheduled time)
  • ensure bylaws and agreements allow block time adjustments if needed
  • Consider staff expertise and willingness to adapt (introducing orthopedic or cardiovascular procedures into a previously GI or ophthalmology-focused ASC may require significant training and staffing changes).

Yoder then posed this question to the audience—which high-revenue specialties make sense for your ASC? She offered the following breakdown:

1. Orthopedics
   • Strong 10–20% profit margins with high revenue per case.
   • Total joints and spine cases require costly capital investments but yield high profitability if well-negotiated payer contracts are in place.
   • Sports medicine procedures (eg, ACL, rotator cuff repair) are now almost exclusively done in ASCs.
   • Equipment needs include beach chairs, arm holders ($15K–$18K), joint replacement tables ($100K+), and helmets for infection control.
   • Robot-assisted surgery requires costly infrastructure updates (electrical and storage space considerations).

2. Cardiovascular (CV) procedures
   • Growing in ASC eligibility, but procedures like electrophysiology (EP) and cardiac interventions still require significant investment in imaging and catheterization lab equipment.
   • Medicare and private payers have begun reimbursing for pacemakers, ablations, and some PCI (Percutaneous Coronary Interventions).
   • Fixed cardiac catheterization labs cost $500K–$750K, requiring specialized space, IT integration, and monitoring systems.

3. Plastics and podiatry
   • Podiatry cases are profitable when avoiding costly implants.
   • Plastics require careful pricing structures—surgeons often go beyond pre-paid procedural plans, increasing unaccounted OR time.

4. General Surgery, ENT, GI, and ophthalmology
   • High-volume, lower-margin specialties that rely on efficient turnover to drive profitability.
   • GI and ophthalmology require high patient volume ("turn and burn" model).

5. Urology and neurology
   • Require lasers, scopes, and consumable implants that can be damaged easily (eg, ureteroscopes with laser burns).
   • High repair costs necessitate careful vendor contract negotiations.

Other key takeaways include:

• Older ASCs may lack adequate electrical capacity, HVAC, and gas lines to support general anesthesia or complex procedures.
• Sterile processing is often underestimated—inadequate sterilizer sizes and sink configurations can create major operational bottlenecks.
• IFUs (Instructions for Use) for instruments continue to change, requiring triple sinks, filtered water, and potentially scope dryers (eg, new Striker guidelines for robotic instruments).

And some parting wisdom from Yoder includes:

• On consumables and implants, be transparent with surgeons—Many are unaware of implant and supply costs until they become ASC owners.
• On avoiding costly vendor agreements, "free equipment placements" from vendors are rarely free—contracts often include inflated consumable pricing.
• Beware of leasing agreements—Long-term equipment leasing often results in higher overall costs compared to outright purchases.
• Neptune placements and filter commitments can quickly become a financial burden if overcommitted to fixed minimum orders.
• Break down costs per surgeon using detailed preference card analysis.
• Create multiyear projected spends for consumables and implants to leverage better pricing.
• Ensure vendor contract transparency—Compare multiple vendors and negotiate regional rep support for case coverage.

Expanding ASC service lines requires a strategic balance of financial planning, facility readiness, and staffing optimization. High-margin specialties like orthopedics and cardiovascular procedures can be highly profitable, but capital costs, staffing needs, and vendor contract structures must be carefully managed. Nurse leaders and administrators play a critical role in ensuring efficient operations, cost control, and patient safety while supporting the ASC’s long-term profitability.