Everybody Says Focus on the Basics. Almost Nobody Means Access.

health systems margin improvement physician groups tactics Oct 22, 2026

What It Costs You Monday — a 10-part series on healthcare margin at the operating level. Start with Part 1: The Opening. Previous: Part 3: Both Directions. You're reading Part 4: The Basics, and the Labor Pool.

Strategy three on the list reads: focus on the basics — seek smart growth, such as adding ambulatory surgery centers, and improve access, emergent care, productivity, revenue cycle management and efficiency.

That sentence has two halves and they point in opposite directions. The second half is the real work. The first half I would strike.

The real work first, because it is the part that gets skipped.

"If you need OR capacity, build it. Just don't call it growth."

THE BASICS, DONE PROPERLY

This is what we do in any margin containment project. Go through all the little parts and pieces — department by department, every line item on the books, re-benchmarking productivity.

And then the operational plans, which people skip. What do your volumes look like? What do your schedules look like? What does your access look like? Then build models that get the right types of patients into the right places.

That last sentence sounds soft. It is where the money is.

WHERE RETENTION ACTUALLY LIVES

We left a lot of revenue on the table in one practice simply because we were not holding onto our patients. The reappointment rate was 60%. We got it to 95% — the whole story, including the accountability structure underneath it, is written up here.

No new providers. No new marketing. No new service line.

That is revenue out of volume you already have, and it is the cheapest revenue in healthcare, because you already paid to acquire the patient. Nobody writes a press release about it, which is most of why it does not get done.

AND THEN THE OTHER HALF OF THAT SENTENCE

Which brings me to ambulatory surgery centers, recommended in the same breath as the basics.

I would think very hard about it — and the reason that matters most is the one people rarely raise.

It drains a labor pool that nobody replenishes.

Surgical techs at a surgery center do not take call. That is very hard to compete with. So the pool of techs and OR nurses willing to take call shrinks. As it shrinks, the call burden on everyone still in it goes up. Which makes those jobs worse. Which pushes more of them out.

We have been through periods where you simply could not get an OR nurse. It is a perpetual cycle and it makes things worse every turn.

Now look at what that actually is. The labor pool is shared. Nobody is responsible for refilling it. Every individually sensible decision takes from it. It is the same shared-pot problem this whole series is about — running on people instead of dollars, which makes it far harder to see and much harder to reverse. You can write down an asset. You cannot write down a profession's willingness to take call.

Two more reasons, briefly, both covered in Part 1. It adds capacity rather than margin — the same volume spread across more sites and a higher cost per case everywhere. And it converts flexibility into fixed cost at exactly the moment you want to stay nimble.

NONE OF THIS MEANS NEVER BUILD

If you need OR capacity, build it. Build it deliberately, for a capacity problem you can name and measure.

What I am arguing against is building one to get into a profitable market. That is a different decision wearing the same clothes, and it is the one that quietly raises everybody's cost — including yours.

The tell is which half of the sentence you started from. Organizations that start from access and retention tend to find they need less capacity than they thought. Organizations that start from growth tend to build first and look for the volume afterwards.

FIVE QUESTIONS WORTH ANSWERING IN WRITING

What is our reappointment rate, and does anybody own it by name?
How much revenue is sitting inside the volume we already have — patients who came once and did not come back?
Are the right types of patients getting into the right places, or are we scheduling by whoever has an opening?
For any site we are considering: can I name the capacity problem it solves, in units?
If we add this, where do the staff come from — and what happens to call for everyone who stays?

The basics are unglamorous, which is exactly why they are still available to you.

Ready to talk about where your organization stands? Book a free strategy session · Connect with me on LinkedIn, where this series runs.

DR Advisors — Physician's Trusted Advisor