Why some practices are looking beyond the traditional ASC model

Physician practices are rethinking where certain procedures should be performed as outpatient care continues to move into more flexible sites of care. For some groups, a traditional ambulatory surgery center (ASC), with its separate facility structure and formal certification pathway, remains the right fit. For others, an office-based surgery (OBS) suite, or a hybrid structure that uses both, may offer more control over scheduling, patient flow, and long-term growth.

Tina DiMarino, DNP, MBA, RN, CNOR, CASC, FACHE, from Custom Surgical Partners, says practices considering ambulatory surgery center development should start with feasibility, procedure mix, compliance requirements, staffing, and payer realities before committing to a facility plan.

That early analysis matters because an ASC and an OBS suite are not simply two versions of the same idea. They can differ in ownership structure, regulatory pathway, reimbursement, build-out requirements, staffing, accreditation, and operational risk. Medicare defines an ASC as a distinct freestanding facility, other than a physician’s office, where surgical and diagnostic services are provided [1]. A Medicare-certified ASC also has to meet federal Conditions for Coverage covering areas such as governing body oversight, surgical services, quality assessment, infection control, and patient rights [2].

An OBS suite may feel more familiar because it sits inside or near the practice environment, but familiarity should not be confused with simplicity. The right site of care depends on what the practice performs today, what it expects to perform later, and what it can manage safely and consistently.

Office-based suites can offer flexibility, but not simplicity

The appeal of an office-based suite is easy to understand. A practice may be able to keep more of the patient experience in one location, reduce scheduling friction, and design the space around its own procedural flow. For some specialties, especially those with predictable case types and carefully selected patients, the structure can look attractive.

That flexibility can be useful for practices that want more control over the daily schedule. It may also help avoid the feeling that the practice is competing for time in a separate facility. A surgeon or proceduralist may prefer an environment where staff, equipment, patient education, and post-procedure follow-up are more closely connected to the clinic.

Still, office-based surgery should not be treated as a shortcut. The practice must be prepared to manage the clinical and operational requirements that come with performing procedures in a non-hospital environment. That can include patient selection protocols, emergency preparedness, infection control, equipment maintenance, credentialing, anesthesia arrangements, documentation, recovery workflows, and transfer planning.

Research on office-based surgery generally supports the idea that it can be safe when patient selection, accreditation, credentialing, and safety processes are handled carefully. A 2018 review in Current Opinion in Anaesthesiology noted that office-based procedures have increased over time and that safety depends on maintaining high-quality care as more procedures move outside hospitals [3]. The practical takeaway is not that every case belongs in an office. The location must match the patient, procedure, team, and safety infrastructure.

For a practice, the first question is not “Can we build the room?” It is “Can we reliably run the room?”

That means looking at how the team will handle pre-op screening, supply management, clinical documentation, patient recovery, staff training, quality review, and unexpected events. If those systems are not mature, an office-based suite can quickly create more complexity than expected.

The hybrid model is changing how practitioners think about growth

Some practices are not choosing between an ASC and an office-based suite as an either-or decision. Instead, they are exploring hybrid arrangements that use the strengths of both.

A hybrid OBS/ASC structure may allow a practice to place certain procedures in an office-based environment while using an accredited ASC for cases that require more structure, different payer treatment, broader staffing, or a more formal facility path. This can be especially relevant for specialties with a mix of low-acuity procedures and cases that require a higher level of readiness.

The hybrid approach is not just about space. It is about strategy.

A practice may want to start with office-based procedures and later expand into a full ASC. Another group may already have an ASC but want an office-based suite for selected cases that do not require the same facility pathway. A multispecialty group may need to think about how ophthalmology, vascular, GI, urology, gynecology, cardiac, or other procedural lines could fit into one operational plan.

The challenge is that hybrid planning requires careful design. Patient flow, payer rules, regulatory expectations, equipment location, staffing patterns, and billing workflows have to be clear. If the structure is poorly planned, the practice can end up with duplicated costs, confused processes, and unclear accountability.

This is why feasibility work matters before design work. Practices need to understand projected case volume, payer mix, build-out costs, staffing needs, reimbursement assumptions, and the timeline for licensure or accreditation if an ASC component is involved. A floor plan can show where rooms go. It cannot tell a practice whether the approach makes business or operational sense.

Hybrid planning also requires an honest look at growth. A plan that works for the first 200 cases may not work for the next 2,000. If the practice expects to add physicians, specialties, anesthesia services, or more complex procedures, the structure needs to support that future rather than only solving the first operational problem.

Why reimbursement, compliance, and staffing still drive the decision

Facility decisions often begin with convenience or control, but reimbursement, compliance, and staffing usually determine whether the approach is sustainable.

For ASCs, Medicare maintains ASC payment files that identify covered procedure codes and payment rates for facility services furnished in connection with covered procedures [4]. That does not mean every commercially insured case will follow the same logic, but it shows why procedure mix and payer analysis are central to ASC planning. A business case can look efficient on paper and still fall apart if the reimbursement assumptions are wrong.

Office-based surgery has its own payer and billing questions. Some procedures may be paid differently depending on whether they are performed in an office, ASC, or hospital outpatient department. Some payers may have specific requirements for documentation, authorization, anesthesia, accreditation, or site of service. Practices need to evaluate those rules before assuming that moving procedures in-house will automatically improve financial performance.

Compliance is another major factor. A Medicare-certified ASC must meet federal requirements, and state rules, accreditation expectations, and specialty-specific standards may also apply [2]. Office-based suites may be subject to state medical board rules, accreditation expectations, payer requirements, or professional guidelines, depending on location and procedure type. That variation makes early legal, regulatory, and operational review important.

Staffing can be just as important as reimbursement. An ASC may require a broader administrative and clinical structure, including leadership, nursing, infection prevention, quality review, credentialing, and business-office support. An office-based suite may appear leaner, but it still needs trained staff, defined roles, emergency protocols, documentation discipline, and oversight.

Practices sometimes underestimate the management load. A suite does not run itself because it is located inside the practice. An ASC does not succeed simply because the practice has strong surgeons. Both structures require leadership attention, process ownership, and ongoing performance review.

The better question is not which option is easier. It is which one can the practice manage well?

A practical framework for choosing the right surgical setting

A useful comparison begins with the procedures themselves. What cases does the practice perform most often? Which patients are appropriate for a non-hospital environment? What anesthesia support is needed? How often do cases run long or require additional recovery time? Which procedures are likely to grow over the next three to five years?

From there, practices can evaluate four areas.

First, the clinical fit. The location should match the procedure, patient risk profile, recovery needs, and emergency preparedness requirements. This is where patient selection and procedure selection become central.

Second, the regulatory and accreditation path. If the plan involves a Medicare-certified ASC, the practice has to account for federal Conditions for Coverage and the work required to maintain readiness [2]. If the plan involves OBS, the practice still needs to understand state, payer, accreditation, and specialty expectations before building around assumptions.

Third, the business case. Case volume, payer mix, build-out cost, staffing expense, vendor contracts, equipment needs, and reimbursement should be modeled before major commitments are made. A feasibility analysis can help show whether the plan is right-sized or overbuilt.

Fourth, the operational capacity. The practice should ask whether it has the leadership, staff training, compliance tracking, scheduling discipline, documentation systems, and quality processes to run the site safely and consistently.

Custom Surgical Partners supports practices and surgery centers as they compare ASC, OBS, and hybrid options, helping them evaluate feasibility, compliance expectations, accreditation needs, operational capacity, and long-term growth plans. For practices comparing facility paths, that kind of structured review can help turn a general growth idea into a clearer decision about scale, timeline, and risk.

Looking beyond the traditional ASC structure does not mean the ASC is becoming less relevant. It means practices are thinking more carefully about matching the surgical environment to their specialty, patients, finances, staff, and future growth. The right answer may be an ASC, an office-based suite, or a hybrid structure. The important step is choosing the path because it fits the practice, not because it looks simpler at first.

References:
[1] Centers for Medicare & Medicaid Services. (2026, February 17). Place of Service Code Set. https://www.cms.gov/medicare/coding-billing/place-of-service-codes/code-sets
[2] Centers for Medicare & Medicaid Services. (n.d.). 42 CFR Part 416 – Ambulatory Surgical Services. Electronic Code of Federal Regulations. Accessed June 16, 2026. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-416
[3] Young, S. M., Shapiro, F., & Urman, R. (2018). Office-based surgery and patient outcomes. Current Opinion in Anaesthesiology, 31, 707-712.
[4] Centers for Medicare & Medicaid Services. (2026, March 10). Ambulatory Surgical Center (ASC) Payment. https://www.cms.gov/medicare/payment/prospective-payment-systems/ambulatory-surgical-center-asc