Endoscopic Submucosal Dissection (ESD) has become an established procedure for resection of pre-malignant lesions. Despite its benefits and cost-effectiveness, there are significant challenges to bring ESD to mainstream practice in the US given the unpredictability of reimbursement. In this lecture, we will discuss the experience of one of the high-volume ESD centers in establishing a sustainable complex endoscopic resection program. We will discuss steps needed to ensure fair reimbursement and financial obstacles facing early adopters of ESD technique in the US.