ASC ownership often runs through acquisition models, in which surgeons join a group with a stake in an existing center or a group of surgeons buy into a practice together.
New construction is a bigger bet. ASCs are commanding the highest rent increases of any outpatient facility type, with rents climbing more than 8% even as leases surged 145% between 2022 and 2025, according to a March 26 report from real estate company CBRE, a sign of persistent demand for standalone outpatient facilities.
Terry Bohlke, CEO of Franklin, Tenn.-based Keystone Surgical Partners said his organization’s pipeline looks different from what he hears elsewhere in the industry.
“We’re seeing a lot of de novos,” Mr. Bohlke told Becker’s. “I’ve talked to some companies and they are really not doing many de novos at all. But that’s what we’re seeing a lot of.”
The physicians behind those projects tend to be early in their careers.
“It’s typically younger physicians who don’t want to pay a high price to buy into granddad’s old surgery center across town,” he said.
Those surgeons are also arriving at ownership conversations with a different baseline than the generations before them.
“In my experience, the younger physicians are more savvy on investment than they’ve ever been,” Mr. Bohlke said. “A lot of them are inexperienced; but they’ve done a good bit of homework typically, and they know that ASCs are a good investment, and they typically want an ASC investment.”
“A lot of their colleagues and classmates have invested in ASC,” he continued. “They have that benefit of having the experience of what their classmates went through, and the comment is usually, ‘You’re not invested in a surgery center? You’re missing out.'”
What they want to build reflects where they expect outpatient surgery to go.
“They want a brand new center. They want to build it efficiently, and they want it the way they want it, where they want it, and they want it technologically up to date,” Mr. Bohlke said. “They want an EMR. They want patient communication. They want efficient collections. They want all that stuff, and so it’s a pretty big change from what we’ve seen, where a lot of physicians have been not really willing to invest in those kinds of technologies.”
Young physicians are working ahead of expected ASC development trends in this way, Mr. Bohlke said, with an eye towards robotics, extensive sterilization capacity and larger ORs to handle growing surgical volumes. That vision comes with a much higher price tag than it would have a few years ago.
“But the problem is that the cost per square foot on a de novo has doubled post-pandemic,” he said. “It has just gone through the roof. It’s so expensive.”
Those costs land before a center generates any revenue.
“ASCs are very significantly fixed cost companies,” Mr. Bohlke said. “Physicians typically spend every dollar they’re going to spend on the ASC before they’ve even scheduled one patient. All that money’s up front, and so the way to make money on a fixed-cost business is just volume.”
For established centers, the shift raises the stakes on bringing the next generation in rather than watching it build across town.
“If you think of your ASC life cycle, because every ASC has one, without a succession plan, that ASC is just going to eventually dry up,” Mr. Bohlke said. “It can’t be a, hey, looking around the boardroom and everybody’s got gray hair and an ache in the back and they’re taking naps in the afternoon. That’s too late.”
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.
