When Ascension closed its $3.9 billion acquisition of AmSurg in June 2025, adding 250 ASCs across 34 states to its network, the FTC forced the nonprofit system to divest seven of those centers before the deal closed.
The deal pushed Ascension’s ASC count from 58 to more than 300, inside a market projected to grow 9% to 12% annually over the next five years, and served as a red flag that ASC acquisitions – often too small to trigger federal regulatory review — may still be subject to scrutiny.
The acquisition, though, is not how Ascension has done most of its outpatient growth. For a decade, the St. Louis-based system has quietly built a nearly $1.2 billion investment portfolio spanning surgery centers, home health, physical therapy and revenue cycle management through a joint venture with TowerBrook Capital Partners that has drawn far less attention.
Ascension and TowerBrook first began investing jointly in 2015, according to a new report by the Private Equity Stakeholder Project that analyzed the last several years Ascension’s investment patterns. The two companies came together to invest in R1 RCM, which counted Ascension for 61% of its business at the time. The two later formalized the relationship into the Ascension TowerBrook Healthcare Opportunities Fund, in which Ascension holds a 95.6% stake. The fund reported a $1.17 billion portfolio as of Dec. 31, 2025, built through stakes in Trimedx, Compassus, US Acute Care Solutions, PT Solutions Holdings and Regent Surgical Health, an ASC operator Ascension partnered with in 2021.
The Private Equity Stakeholder Project argues that structuring the relationship as a fund investment, rather than an acquisition, is what has let it largely avoid the premerger review that came with the AmSurg deal. The structure also lets Ascension treat the fund’s income as mission-related rather than taxable, under a 1998 IRS ruling that opened the door for nonprofit hospitals to profit from for-profit partnerships.
The financial upside has been most visible for the executives now running the portfolio. Anthony Tersigni, Ascension’s former CEO, saw his pay rise 43% to $10.6 million as chair of Ascension Capital, while former CFO Anthony Speranzo’s pay rose 242% to $10.9 million as the unit’s president and CEO, according to to PESP.
In a November 2025 investor statement, TowerBrook said it “leverages their relationship with Ascension, one of the largest nonprofit healthcare systems in the U.S., to provide the firm with a competitive advantage in sourcing healthcare investments.”
Ascension has been explicit that it sees its own ASC strategy as replicable. In announcing the AmSurg deal, the system said the acquisition “serves as a platform for other nonprofit systems to accelerate that ASC growth” — and several already have. Bon Secours Mercy Health, OhioHealth, Intermountain Health and Providence have all struck similar joint ventures with private equity-backed ASC platforms, including Surgery Partners and USPI, over the past three years.
The PESP report found more than 500 healthcare facilities nationally are now operated through joint ventures between private equity firms and nonprofit systems, including more than one-fifth of all PE-owned hospitals and 61% of Lifepoint Health’s hospitals.
“Private equity’s healthcare playbook is evolving,” Jim Baker, the group’s executive director, said in the report. “Our research documents how private equity has increasingly relied on joint ventures with nonprofits to expand its presence in healthcare.”
Sean Gipson, CEO and ASC division president of Remedy Surgery Center in Houston, told Becker’s that the FTC’s approach to the deal signals a shift in how regulators view the ASC space.
“The key insights and what they mean in practical terms are simple. The FTC is defining ASCs as highly localized monopoly markets,” he said. “The order requiring divestiture of seven ASCs reflects the FTC’s view that competition is not national or even statewide, it is metro-area specific and service-line specific (GI, ortho, ophthalmology).”
This means that federal regulators may begin applying more scrutiny to “zipcode-level surgical markets” where a single deal can significantly shift power dynamics among outpatient surgery lines.
While some argue that regulatory bodies have not caught up to new waves of M&A strategy, Ascension’s most recent playbook could be the beginning of a new era of antitrust enforcement as ASCs move from a desirable to an imperative aspect of health system growth strategy.
“If FTC is increasingly skeptical of ‘health system and ASC platform’ convergence, this deal fits a larger enforcement trend. Hospitals acquiring ASC platforms are vertical and horizontal expansion,” Mr. Gibson said. “The risk is steering, referral control, and negotiated pricing leverage and the result is reduced bargaining power for commercial payers. So if the FTC’s concern is not just ‘too few ASCs,’ but also potential payer leverage shift toward integrated systems and reduced independence of physician-led ASCs.”
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.
