Ask ASC leaders where the industry is headed and most agree that the industry is headed toward more volume, more acuity and more procedures migrating out of the hospital.
Where many ASC leaders disagree, however, is when it comes down to who should own the centers capturing that shift.
The scale of that disagreement shows up in the numbers. Medicare-certified ASCs grew from 5,217 in 2011 to 6,468 in 2025, and despite that expansion, roughly 65% of freestanding ASCs remain independently owned and operated, according to VMG Health’s 2026 Healthcare M&A Report. The remaining 35% is controlled by a small group of large platforms.
On one side is a consolidation thesis, playing out in deal volume across the country as private equity firms and health systems continue acquiring independent centers.
“I think we are going to see more scale, tighter payer alignment, health system partnerships, physician group integration and operational standardization as ASCs try to be more efficient and maintain the profit margins they have enjoyed,” Elizabeth Coombes, regional administrator of Gastro Health Endoscopy Edmonds, Fremont and Kirkland in Washington, told Becker’s. “The ASC industry is consolidating because independent centers increasingly need scale, capital, payer leverage, physician alignment and operational sophistication to compete in a more complex outpatient surgical market.”
That 35% breaks down to a handful of names. By center count in 2025, United Surgical Partners International — Tenet Healthcare’s outpatient arm — holds about 8% of the market, SCA Health (owned by Optum and UnitedHealth) has 4.9%, Amsurg 3.9%, HCA Healthcare 2.3%, and Surgery Partners (39% owned by Bain Capital) 2%, with an estimated 13.8% spread across other multisite operators, according to VMG Health.
Thomas Hutchinson, administrator of the Surgery Center of Central Florida in Ocala, described the same dynamic as one of the “loops and corkscrews” on an otherwise promising ride.
“Private equity firms and health systems are continuing to invest in and acquire ASCs,” he said. “While these partnerships can provide capital, resources and growth opportunities, they also introduce new operational dynamics, governance structures and strategic priorities that can fundamentally change day-to-day operations.”
The clearest example of that consolidation push is Ascension’s acquisition of Amsurg, which operates more than 250 ASCs nationwide, for approximately $3.9 billion. The deal would push Ascension’s total ASC count past 300, making it a top-tier competitor among major multisite operators by center count, a scale previously reached only through landmark deals like the 2015 Tenet-USPI merger and the 2016 Envision-AmSurg merger.
Regulatory tailwinds are accelerating the underlying shift regardless of who ends up owning the centers. CMS’ ASC payment final rule, released Nov. 21, 2025, included a 2.6% increase in overall ASC payments — more modest than the 2.9% bump for CY2025 — but the same rule finalized a plan to eliminate the inpatient-only list entirely over a three-year period starting in 2026, beginning with the removal of 285 procedures.
That follows a 2025 rule that added just 21 new procedures to the ASC Covered Procedures List, a number many operators saw as too conservative given how fast higher-acuity cases are already moving to the outpatient setting.
On the other side is a bet that physician ownership, not scale, is the more durable advantage, particularly as patients and employers begin shopping directly for site of service and price.
“The outpatient migration story is settled,” said Sumana Moole, MD, founder of Merus Gastroenterology & Gut Health in Suwanee, Ga. “The real question for the next decade is who owns the surgical asset. Physicians who own their centers control the three things that used to belong to health systems: the site of service, the price and the patient experience. Employers and patients are now shopping on exactly those terms, and they are coming to us directly. Consolidation will keep accelerating, and plenty of owners will take the check. The centers that stay physician-owned, negotiate their own commercial and employer contracts, and build a genuinely consumer-grade experience will not just survive that wave. They will set the market. The ones that sell early will spend the next 10 years operating inside someone else’s economics.”
In 2025, Surgery Partners rejected a full buyout offer from Bain Capital, the same firm that already owns about 39% of the company, choosing independence over a private equity exit. Instead, the company said it would reinvest in de novo centers, physician-aligned growth and select acquisitions.
“De novos represent an exciting growth prospect for Surgery Partners, given the low cost of entry and opportunity to bring the scale of our operations to growth-oriented partners,” said Eric Evans, CEO of Surgery Partners, on the company’s Q1 2025 earnings call. “Although they take time to develop and construct, the effective multiples on these assets are a fraction of traditional acquisition multiples.”
Marcelo Hochman, MD, an independent physician and former president of Independent Doctors of South Carolina in Charleston, sees the independence path going even further, away from insurance contracting entirely.
“Those ASCs that can get out of the ‘insurance game’ and move to a cash basis will have an amazing opportunity for growth,” he said. “Direct-to-employer contracts will flourish; patients will get great value and the owners will make more money.”
EJ Ledesma, CEO of 360 Orthopedics in Sarasota, Fla., framed the difference in ownership models as a difference in how the two build.
“Hospitals build systematically. ASCs get built opportunistically,” he said. “A few reasons why: Continued payer compression and escalating costs can serve as a catalyst for those physicians who have the volume and business sense to pursue an ASC strategy. If planned properly, an ASC is more flexible in its ability to design efficient workflows, allocate capital and pivot when necessary.”
Valuation trends suggest both sides have reason for confidence. VMG Health’s tracking of total invested capital-to-EBITDA multiples shows the median ASC transaction multiple rose to 7.9x in 2025, up from 7.6x in 2024, with the 75th percentile reaching 8.1x, a lift VMG attributes to easing financing conditions and growing competition for high-quality assets.
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.
