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Interview by Jodie Elrod

Wilber Su, MD, FACC, FHRS, is the Director of Heart Rhythm Services at Banner-University Medical Center and Professor of Medicine at the University of Arizona. In this interview, he discusses his moderated session, entitled "Business of EP I: To ASC or Not to ASC: The Great Debate in the Business of Electrophysiology," at Heart Rhythm 2026.

What key factors are driving the growing interest in ambulatory surgery centers (ASCs) within electrophysiology (EP) right now?

Several factors have converged to drive a surge of interest in the ASC setting, particularly within EP.

First is the refinement of EP procedures, evolving from device implantation to, more importantly, ablations. Procedures such as atrial fibrillation (AF) ablation—which 15 to 20 years ago were considered complex and could take hours to complete—are now routine outpatient procedures with same-day discharge. Advancements in ablation technology, including the introduction of the cryoballoon nearly 2 decades ago and, more recently, pulsed field ablation, along with robust clinical evidence from studies such as EARLY-AF and Cryo-FIRST, have elevated ablation to a first-line therapy.

The growing demand for EP procedures underscores the need for a more efficient and patient-centric treatment strategy. Several key factors have driven this shift, notably the Centers for Medicare & Medicaid Services (CMS) coverage for AF ablation in the ASC setting, which helped remove a major financial barrier. In addition, the emergence of physician ownership models has enabled a more autonomous, revenue- and efficiency-oriented approach to care delivery.

This shift has also moved lower-complexity procedures out of hospitals, allowing physicians to offer a more cost-conscious solution to the rising cost of AF care. In general, the cost to insurers for providing ablation care can be 30% to 50% lower in the ASC setting compared to the hospital setting, creating a win-win solution for all parties involved.

As moderator, what perspectives or trade-offs are you most interested in highlighting during this debate?

Having just started and become involved in a physician co-owned ASC model—perhaps the first academic ASC in the U.S., with 6 electrophysiologists and 3 interventionalists and continuing to grow—this has been a significant learning experience. The factors at play are closely intertwined, with utmost importance placed on patient safety and outcomes, alongside economic incentives from both payer and provider perspectives.

From a safety standpoint, even procedures like AF ablation, which are now well established, still carry risks and reflect varying levels of physician comfort. Anesthesia support and complication mitigation are critical considerations that must be prioritized in the planning and operation of an ASC.

At the same time, some of these incentives inevitably compete, as cost, value, and technology are not always aligned. Physician comfort in managing complications—such as cardiac tamponade, for example—varies widely, yet these are events that will occur and must be managed by the operator. The standard of care also remains a moving target, depending on oversight.

Hospital administrators, who may see routine, lower-complexity cases shift away from hospital settings and off their revenue balance sheets, will need to consider how to partner with physicians to make the ASC model mutually beneficial. Insurance providers may benefit from the lower cost per case, but may also need to pay closer attention to appropriateness and standards, as the overall cost of patient care could increase due to complications or a surge in procedure volume.

What should attendees be thinking about when evaluating whether the ASC model is the right fit for their practice or institution?

In terms of serving the patient, the ASC model must, above all, provide a safe and effective procedural environment. Planning and establishing an ASC is a complex process that requires careful management, and learning from the mistakes of other ASC startups is an important first step.

Key challenges include contracting rates for procedure reimbursement, staffing for the ASC environment, and supply management to control cost per case. Any of these issues can jeopardize an ASC, turning a financial investment into a liability and a source of ongoing difficulty. Forming partnerships with the right stakeholders is critical to addressing these challenges and to creating a win-win situation for all parties involved, including hospitals, insurance providers, and physicians.

This session will hopefully provide valuable insight into these considerations and foster more meaningful discussion across different employment and private practice models when evaluating the ASC opportunity.