Physician ownership of ASC has become a highly consequential factor shaping the future of the industry.
Reimbursement is tightening, corporate buyers are aggressive and physicians are increasingly shifting toward employed settings.
For those still debating going into ownership or navigating their first years as owners, the surgeons who built ASCs from the ground up have hard-won lessons to impart that medical training never covers.
That gap between clinical training and business fluency was a recurring theme at Becker’s 23rd annual Spine, Orthopedic and Pain Management-Driven ASC + The Future of Spine Conference in Chicago June 11-13, where surgeon-owners, administrators and healthcare attorneys laid out what physicians actually need to understand before — and after — they sign onto ownership.
Case mix is the number most owners ignore
Ken Rich, MD, medical director and chairman of the board at Raleigh (N.C.) Neurosurgical Clinic — which owns its own ASC and has grown from two neurosurgeons to nine since 2013, said much of case mix management comes down to efficiency.
“Well, there’s a lot more to it. What’s the value of each of those surgeries? If you have one guy doing a 4 1/2-hour long lumbar instrumented fusion, well, gee, that’s a nice reimbursing case,” he said. “But if somebody else could have done that in two hours, that’s not quite as good a case. And I’m not knocking the pain guys, because our pain guys do a lot of good work in the surgery center, but we don’t get reimbursed as much for that. Our profit margins aren’t as good. So, if you don’t look at that number and go, oh, we’ve got X procedures, how many are in pain? You’re not understanding the economics of the surgery center. And if you don’t understand those, you can’t maximize the profits of the surgery center,” Dr. Rich said.
The discipline to read a case mix report is often something many surgeon-owners pick up only after it has already cost them. For practices considering a partnership with a health system or selling equity to a corporate buyer, a weak case-mix story also weakens the valuation.
Autonomy is the real asset — and the first thing to go
“Independence drives physician performance every time,” Kevin Plancher, MD, founder of Plancher Orthopaedics and an independent ASC owner in New York City, said at the conference. “Once you give up autonomy, it’s surrendered. It’s gone.”
That warning carries particular weight in 2026, when the confluence of corporate offers and rising student debt can make it challenging for younger physician owners to continue choosing independence.
Dana Jacoby, president and CEO of Vector Medical Group, which advises physician groups on transactions, noted that six large orthopedic groups were actively going to market in 2026, more than she could have said in 2025. The first wave of orthopedic roll-ups from 2021 and 2022 are reaching maturation, and second bites — or continuation funds — are reshaping what the exit looks like.
The case against a full sell-off is not that private equity is predatory by nature, but that its incentive structure and time horizon rarely align with a surgeon who expects to practice for another 20 years. Dr. Plancher’s summary of what physicians exchange in a PE deal: “buying power, administrative relief, liquidity. But what the young doctors don’t know is physicians make less. Ultimately, care declines in my opinion. Wait times go up and liquidity is a one-time event.”
The antidote, several panelists argued, is not a reflexive rejection of outside capital but a precise understanding of what is being exchanged for it — and a governance structure that preserves real physician control.
What makes a partnership actually work
Raleigh Neurosurgical’s current conversations with Duke University’s health system offer a useful case study. Duke needs ASC space; payers are pressing the system to move cases out of the hospital. Raleigh Neurosurgical has the space and the track record. Dr. Rich’s calculus is simple: Duke brings volume, Raleigh Neurosurgical brings efficiency, and both sides know the surgeons are quality.
“It works for you in that you keep your insurers happy. It works for us in that the ASC gets more cases brought in,” Dr. Rich said. “And we know the surgeons at Duke. We’ve known them for forever, so we know they’re good quality people who are going to do the kind of work you want done at an ASC.”
What separates partnerships that work from ones that collapse is not just deal structure — it’s alignment of mindset and time horizon. Faisal Rahman, a member and owner of Munster Surgery Center in Munster, Ind., who has spent 30 years advising physician groups, said that transparency is key for partnerships.
“If they are not willing to share information about their other deals’ partners, then you should be suspicious. Talk to your own lawyers. And if the lawyer cannot explain to you what the operating agreement stands for, maybe there’s something wrong with the operating agreement,” Mr. Rahman said.
Gary Herschman, healthcare transactions shareholder at Baker Donelson, who has worked on orthopedic, spine and pain deals throughout his career, echoed the governance theme directly: the platforms that underperform are invariably the ones where private equity investors are trying to operate the practice rather than fund it. The platforms that succeed are where physicians remain in charge of clinical and operational decisions.
“Real governance is the absolute key to this. If it is governance in name only, or they don’t feel that way, they’ll continue to disengage,” said Paul Eichenseer, DO, chief physician officer of Cincinnati, Ohio-based OrthoAlliance regarding a new physician compensation model rolled out in early 2026 aimed at reversing disengagement after a large orthopedic roll-up.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
