Image by Pexels from PixabayIf 2026 is shaping up to be a defining year for the ambulatory surgery center (ASC) business model, it is also one that will test its limits.
Rising labor costs, payer complexity, anesthesia shortages and margin pressure are operational realities that executives are confronting daily. The shift of higher-acuity cases into outpatient settings continues, but the economic and workforce infrastructure needed to support that growth has not always kept pace.
For many operators, the challenge is no longer whether ASCs can take on more complexity, but whether they can do so sustainably.
What’s more, as the industry matures, long-standing pressure points are colliding with newer ones. Consolidation has thinned the acquisition landscape. Medicare Advantage penetration has altered reimbursement dynamics. Hospitals and health systems are competing more aggressively for surgeons, anesthesia providers and nursing talent. At the same time, inflationary forces continue to push up supply, implant and staffing costs in a sector that has little room to absorb them.
To better understand these and other challenges, ASC News asked several industry leaders the following question as part of our Executive Outlook project:
For your ASC specifically, or for those you work with if you’re on the industry-partner side, what do you see as the top challenge to overcome in 2026, and why?
Their responses are below, edited for style, length and clarity. Part I of our Executive Forecast – focused on 2026 predictions and opportunities – was published on Dec. 15, 2025.
Travis Messina, CEO, Regent Surgical
We anticipate several challenges in the coming year that make relying on the old playbook for success no longer viable. Physician employment patterns have shifted dramatically, with most surgeons now employed by hospital systems, physician groups, or other organizations rather than practicing independently. At the same time, our payer mix has evolved with more Medicare Advantage beneficiaries, bringing lower reimbursement rates, stricter prior authorization requirements, and a heightened need to demonstrate value through outcomes data rather than volume alone.
Compounding these pressures, rapid consolidation has reduced the number of high-quality ASCs available for acquisition, further reshaping the competitive landscape.
To thrive in this environment, leaders must bring differentiated capabilities and invest in infrastructure. Success in 2026 will require robust IT systems and advanced analytics to meet payer demands and manage the complexity of multiple Medicare Advantage contracts. Regent has integrated electronic medical records and data aggregation across our network, not as a competitive edge, but as a necessary foundation to scale efficiently and deliver the outcomes reporting that payers, employed physicians, and health systems now expect.
DJ Hill, Former CEO and Current Board Chair, Compass Surgical Partners
One of the biggest challenges we will continue to see in 2026 is maintaining strong margins in an environment where supply and implant costs continue to climb. ASCs have always operated on tight economics, and inflationary pressure makes disciplined supply-chain management more critical than ever.
For my team, this means staying ahead of volatility, negotiating wisely, and working closely with our surgeons to choose high-value products that support excellent outcomes without compromising sustainability. It’s not a new challenge, but the stakes are higher — and the organizations that navigate it well will be the ones positioned for long-term growth.
(*Editor’s note: Compass Surgical Partners named Mark Langston its new CEO at the start of 2026. Hill remains actively involved as board chair, according to the company.)
Waleed Nasr, Co-Founder and CEO, Medely
In 2026, I think the biggest challenge ASCs will face is balancing the rising cost pressures with quality and consistent staffing. Facilities are caught in a constant juggling act because labor is the single largest operating expense, yet the workforce shortage means they’re competing for the limited available professionals. It’s a tough paradox. And with thin margins and staff turnover costing over $61,000 per RN, retention is critical, but even harder when teams are stretched thin. The real solution is moving away from fragmented, reactive staffing and using tools that give leaders a clear, centralized view of their whole workforce. With that visibility, administrators can place people where they’re needed, reduce burnout, and keep coverage steady so both patients and staff have a better experience.
Steve Hockert, Chief Development Officer, Solara Surgical Partners
The biggest challenge will be the workforce and leadership bandwidth. Not just staffing – but developing the next generation of ASC leaders who can manage growth, keep up with payer complexity, and maintain high clinical standards. As the industry expands, the demand for skilled administrators and OR leaders is outpacing supply. Staying proactive with recruitment, training and retention is critical for sustaining momentum.
The toughest challenge will be managing rising operating costs, especially anesthesia subsidies and staffing in a year when reimbursement may not keep up.
Danilo D’Aprile; VP Business Development, Merritt Healthcare; President, AASCA
Anesthesia subsidy requests are increasing across the country. Recruiting anesthesiologists and CRNAs is harder, compensation is rising and hospitals are competing aggressively. Add in the ongoing shortage of experienced ASC nurses and surgical techs, and staffing becomes one of the biggest constraints on growth.
If site-neutrality ends up reducing ASC rates, those pressures get even harder to absorb. So the challenge will be growing intelligently while keeping operations tight and sustainable.
Todd Currier, CASC, CPA, FACMPE, Treasurer of the ASCA Board; CEO/Administrator of Bend Surgery Center in Bend, Oregon
We continue to see challenges in recruitment at all phases, surgeons, anesthesia, nursing and technicians. These shortages will continue into 2026 and remain an important part in how we manage and adjust to the market conditions.
Chris Schriever, Co-Founder and CEO, ASCdata
That’s a tough one – it’s likely a tie between securing anesthesia coverage and managing rising operational costs.
Anesthesia is no longer just a cost of doing business; it is a critical operational expense that dictates the OR schedule and requires budget-busting stipends. The scarcity of anesthesia providers is putting ASCs in the position of competing directly with hospitals, driving up labor costs and creating scheduling disruptions. If ASCs cannot secure stable, cost-effective anesthesia models, they risk ceding surgical volume and facing significant margin compression, regardless of strong reimbursement for the procedure itself.
At the same time, operational costs are rising faster than payer reimbursement. It starts with the suppliers themselves, who are still grappling with general inflation, higher component costs and supply chain disruptions. This means increased prices for medical supplies, implants, and equipment – all of which directly impact ASCs by further squeezing their already narrow operating margins. Unlike many other industries, ASCs have limited ability to pass these increased costs along to payers or patients.
Jessica M. Rodriguez, MBA, CASC, ASCA Board Member and Executive Director of OAM Surgery Center at MidTowne in Grand Rapids, Michigan
Our ASC is a 100% physician-owned orthopedic center, so many of our challenges originate on the physician side. Reimbursement for surgeons continues to decline while the cost of operating a practice and an ASC rises. This creates mounting pressure on independent groups – particularly with recruitment, where we compete directly with large health systems that can offer significantly higher compensation packages. It also reinforces the need to maximize ASC performance and profitability, since distributions often represent an increasingly essential portion of physicians’ income streams.
Lisa Austin, Senior Advisor, Avanza Strategies
Anesthesia coverage and stipends continue to be a big issue that ASCs are dealing with. These issues loom larger in more metropolitan areas where there is more ASC competition. Insurance companies are not covering the stipends that ASCs are being required to pay to ensure coverage, so the revenue has to come from cost savings in other areas.
Staff shortages and pay are still a factor, so there is no room to shift funds in that area. Volume and supply costs are the areas that will require the greatest focus. Bringing in more higher revenue cases is key, but also a higher volume of less complex cases with fast turnover can help as well. ASCs need to evaluate supply usage annually, or more as necessary. This should really be looked at as inventory is being conducted to determine high usage supplies that can be negotiated for better volume pricing. Also looking at items that don’t move quickly. These items should be evaluated to determine if they are actually needed or if there are other options to move the supplies quickly.
Keith Smith, Medical Director, Surgery Center of Oklahoma
The top challenge for the Surgery Center of Oklahoma will be to manage and balance the growth of cases with a growth in staff. Cases ahead of staff or staff ahead of cases will challenge us this next year, even more than in previous years, I predict.
Tim Fuchs, Chief Growth Officer, nimble solutions
The biggest challenge will be managing cost pressures without degrading throughput or revenue capture. In 2026, ASCs face a convergence of pressures:
– Rising implant costs and vendor negotiation volatility
– Labor scarcity, especially for specialized perioperative staff
– Payer carve-outs narrowing, forcing tighter margins
– More complex procedures shifting outpatient without matching reimbursement
– Increased administrative work driven by payer “documentation escalation”
The challenge is preserving profitability while growing case volume and maintaining a high surgeon experience. ASCs that cannot standardize workflows or modernize RCM will feel the squeeze first.
