The ASC industry has been on a steady growth path in recent years as ambulatory developments shift to the center of health system growth strategies and third-party groups continue to capitalize on opportunities for mergers and acquisitions in the space.
Recently, Brentwood, Tenn.-based Surgery Partners closed a $797 million sale of its two remaining hospitals to Intermountain Health this month, shedding inpatient assets to focus entirely on outpatient surgery.
“With the completion of this important transaction, Surgery Partners enters a new chapter better positioned for long-term growth as a pure-play short-stay surgical provider,” CEO Eric Evans said.
In another major industry play, Ascension folded AmSurg into its network and now counts more than 312 ASCs across 36 states. A recent analysis of the outpatient real estate market found physician ownership participation, not demographic demand, is now the strongest predictor of whether a new ASC succeeds. The capital chasing surgery centers is not chasing buildings — it’s chasing the physicians who fill them, and how those physicians get paid to give up, or keep, control.
Management services organizations have become the preferred vehicle for that trade. Physicians affiliate with an MSO that handles billing, payer contracting, compliance and other administrative functions for a management fee, while retaining clinical decision-making and, increasingly, an ownership stake. The pitch typically revolves around access to capital and scale without well-documented the loss of autonomy that has pushed physicians out of employed practice in the first place.
Physicians in physician-led organizations report 81% satisfaction with their role in strategic decision-making, compared with 50% among those in hospital-led practices, per a Bain & Co. survey.
Charleston, S.C.-based independent physician Marcelo Hochman, a former president of the Independent Doctors of South Carolina, has watched colleagues make that trade.
“The allegiance of the employer to the employee is much weaker than the other way around,” Dr. Hochman told Becker’s. “It’s just not under your control.”
“You become a very small cog in a gigantic wheel,” he said. “Burnout happens when you lose autonomy — it’s what people call moral injury: being forced to practice in a way that goes against what you would do if you had total control.”
Full independence has its own price. Health systems now report a median investment of $314,231 per physician FTE, with total direct expenses per provider reaching $678,119 in the second quarter of 2026. Private equity has invested $1 trillion in healthcare over the past decade, even as PE-involved deals are expected to fall by roughly half in 2026 amid tightening state oversight — and 25 states have now enacted or proposed laws restricting private equity’s role in healthcare.
That squeeze — too expensive to stay independent, too risky to sell outright — has pulled MSOs to the center of the ASC market, even as the model keeps scaling. Les Jebson, administrator of the Orthopedics and Sports Medicine Network at Prisma Health in Greenville, S.C., told Becker’s that consolidation is moving beyond single-market “super groups” into multistate “hyper groups” of 500 to 2,000-plus clinicians. Hospital and health system mergers totaled 86 announced transactions across 2025 and the first half of 2026, and health system ownership of orthopedic practices in Southern states has grown 140% over that period. More than half of orthopedic specialists still practice independently, Mr. Jebson notes, but the direction favors scale.
Beyond physician ownership, the Northmarq report found health system relationships, insurance contracts and operational execution round out the four factors separating a successful ASC from a struggling one. One Houston-area surgical hospital illustrated the fix: squeezed by falling reimbursement after the pandemic, its physician owners restructured into a three-way joint venture — a large health system handling payer contracting, a specialized operator managing staffing, and physicians retaining their financial stake, and with it, a seat at the table.
A newer generation of MSOs is building that seat into the model from the outset. NueHealth, a privately held ASC operator, argues its ownership structure is itself a form of protection for physicians.
“Being privately held allows us to make decisions based more on long-term value than quarterly results,” CEO Michael Sheerin told Becker’s.
Orthopedic Solutions Management, a majority physician-owned MSO based in Tampa, Fla., built its model around what CEO Ravi Chari, MD, calls an “ECG” framework: the right economics, clinical autonomy and real governance rights for physician partners. The company has completed 23 partnerships, now serving roughly 220 physicians, with equity stakes offered to draw in newer physicians seeking ownership.
That governance language is increasingly a legal requirement, not just marketing. The management fee is the financial engine of the MSO model, but regulators treat those fees as presumptively risky because the MSO and the practice sit in an interdependent financial relationship touching patient referrals. To fit within an Anti-Kickback Statute safe harbor, an MSO agreement must be in writing, run at least a year and set compensation in advance at fair market value, independent of referral volume. Stark law requires the same standard, and the Office of Inspector General has made clear meeting one doesn’t automatically clear the other.
In states with strict corporate-practice-of-medicine rules, an inflated management fee can be treated as a constructive fee split, putting both the agreement and a physician’s license at risk. Overvalued fees are also increasingly showing up as EBITDA write-downs when MSO-backed platforms sell — meaning the same governance and compensation structures physicians want for autonomy’s sake also protect an MSO’s valuation down the line.
None of this resolves whether MSOs represent independence or a slower-moving version of the consolidation physicians say they’re trying to escape. What’s changed is the leverage: physicians affiliating with an MSO today are less likely to accept a generic management contract and more likely to ask what governance rights, equity stake and fee structure come with it — and the MSOs building ASC platforms are increasingly competing on the answer.
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.
