ASC consolidation is not slowing because independent operators are getting stronger. It’s slowing because the financial math that made acquisitions irresistible no longer works.
The roll-up era produced a significant national footprint. Dallas-based United Surgical Partners International, Brentwood, Tenn.-based Surgery Partners, Deerfield, Ill.-based SCA Health and AmSurg — now part of St. Louis-based Ascension following a $3.9 billion acquisition that closed in June — have collectively acquired hundreds of centers over the past decade. Many high-volume metropolitan markets have experienced substantial consolidation already.
Nearly 2,000 ASCs are now affiliated with a national chain. Chain operators now control about 33.5% of freestanding ASCs, with the remaining 66.5% still held by independents.
But the conditions that fueled that growth have shifted. Median healthcare services EV/EBITDA multiples declined to approximately 11.5x in 2025, down from 14.5x in 2024, according to Focus Investment Banking. This compression makes aggressive roll-up strategies harder to sustain than they were at the 2021 to 2022 peak.
Indran Indrakrishnan, MD, CEO of Carlsbad, N.M.-based GDC Endoscopy Center, identified six forces pushing consolidation forward: aging physician owners seeking succession plans, rising regulatory and compliance burdens, escalating labor costs in nursing and anesthesia, payer pressure demanding scale and negotiating leverage, growing technology and cybersecurity requirements, and health systems seeking outpatient growth.
Each of those pressures generally favors larger organizations with capital and administrative infrastructure over independent operators running lean.
The anesthesia cost pressure is the most acute near-term example. The share of ASCs expecting to pay anesthesia stipends jumped from 28% to 44% in a single year, according to Itasca, Ill.-based VMG Health. This fixed cost compounds, regardless of case volume and is harder for single-site independent centers to absorb than for national platforms with negotiating leverage across multiple markets.
The ceiling, when it comes, will be shaped by forces working in the other direction, Dr. Indrakrishnan said. He cited physician autonomy, local referral relationships that do not standardize easily across national platforms, growing antitrust scrutiny and the changing economics of private equity dealmaking.
“Private equity’s earlier playbook relied heavily on cheap debt and expanding valuation multiples,” he said. “Higher interest rates and tighter reimbursement make acquisitions less lucrative than they were several years ago.”
The antitrust dimension is also shifting. The Federal Trade Commission’s June 2026 consent order requiring Ascension to divest seven ASCs before closing its AmSurg acquisition was the first time federal regulators applied that level of scrutiny to an ASC-specific transaction. The FTC framed competition as a local, market-by-market question — a standard that puts pressure on any acquirer building density in specific geographies or service lines, not just on national platforms.
For GI specifically, Dr. Indrakrishnan places consolidation in the “middle-to-late middle innings.” He said GI is slightly further along than the broader ASC industry, reflecting that the specialty has been an acquisition target longer than orthopedics or cardiology and that large GI-focused platforms including GI Alliance are already well established. Colonoscopy reimbursement has dropped 38% over 15 years, according to the American Society for Gastrointestinal Endoscopy, creating the kind of margin pressure that historically accelerates consolidation as independent operators struggle to sustain profitability alone.
According to Dr. Indrakrishnan, consolidation is not the primary threat to well-run centers in desirable markets, margin compression is. Reimbursement pressure, anesthesia costs, labor shortages and increasing Medicare penetration are what will determine who sells and who stays independent.
“The key strategic question is no longer, ‘Will consolidation occur?'” Dr. Indrakrishnan said. “But rather, ‘Can we remain sufficiently efficient and profitable to stay independent by choice?’ That distinction will determine who sells and who continues to thrive independently.”
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.