Perioperative medicine represents one of the most economically consequential domains within modern healthcare. Surgical services generate a substantial share of hospital revenue while simultaneously driving significant expenditure. This chapter examines the economic architecture of perioperative practice, emphasizing how anesthesiologists—through clinical, operational, and strategic leadership—affect both sides of the cost–value equation. It delineates the major direct cost drivers of perioperative care, including operating room utilization, staffing models, medication and supply efficiency, post-anesthesia care unit (PACU) flow, and management of case cancelation. The discussion then extends to downstream economic effects, such as reductions in complications, readmissions, and hospital length of stay, demonstrating how perioperative interventions yield measurable savings and improved outcomes. The chapter explores perioperative medicine’s alignment with value-based payment models, highlighting anesthesiologists’ role in bundled payment, pay-for-performance, and cost avoidance initiatives. It also evaluates the contribution of technological innovation—including informatics, predictive analytics, and telemedicine—to perioperative efficiency and cost containment. Finally, it underscores the anesthesiologist’s strategic influence on institutional performance, reputation, and population health through initiatives such as enhanced recovery protocols, preoperative optimization, and the perioperative surgical home (PSH) model. By integrating clinical excellence with financial stewardship, perioperative medicine positions anesthesiologists as essential architects of both patient outcomes and healthcare sustainability.