The FTC’s consent order requiring Ascension to divest seven ASCs before closing its $3.9 billion acquisition of AmSurg sent a clear message to the industry that outpatient surgery is valuable enough to fight over, and regulators are now watching local markets, not just national footprints.
Becker’s asked seven ASC leaders what the order means for consolidation, independent physicians and the competitive landscape going forward.
Editor’s note: Responses were edited lightly for clarity and length.
Shakeel Ahmed, MD. CEO of Atlas Surgical Group (St. Louis): I view this consent order as a defining moment for the ASC industry. For years, ambulatory surgery centers were treated as smaller, physician-led alternatives to hospitals. This order shows that regulators now understand what many of us in the field have known for a long time: ASCs are no longer peripheral assets. They are central to the future of surgical care.
The FTC’s concern is not merely about ownership. It is about local market power. When too many outpatient surgical assets fall under one corporate umbrella, patients, payers, and independent physicians can lose leverage. Prices can rise, referral patterns can narrow, and the very innovation that made ASCs attractive can be diluted.
At the same time, the order confirms the extraordinary value of ASCs. A multibillion-dollar transaction, even with required divestitures, tells the market that outpatient surgery is where healthcare is headed. My opinion is simple: Consolidation will continue, but it must not destroy the independent, entrepreneurial spirit that made ASCs efficient, physician-driven, and patient-friendly in the first place.
I have been voicing my concerns for years regarding the surreptitious violation of the antitrust laws by larger institutes around the country. This is one of those pushbacks that was needed in our industry by the regulators. The FTC issued the consent order because it believed the transaction, as originally structured, could violate antitrust laws in certain local markets.
Janet Carlson. Founder of Vertex Surgical Solutions (Louisville, Ky.): Antitrust scrutiny has now entered the ASC sector — though we’re used to it with payers and hospitals, this is a new dynamic for our space. What’s significant is that regulators are now centering on local market concentration, specific to local markets rather than at a national scale. That puts organizations like Ascension under long-term monitoring in affected metropolitan areas, and the industry-wide implications are real. Consolidation strategies are going to face a lot more friction, longer timelines, and a higher assumed regulatory risk.
I’m also skeptical about six of the seven divested ASCs being sold to Optum. Payer-aligned platforms like SCA, which is Optum-owned, are still favored as divestiture buyers — so even when one entity has to divest, another is eligible to consolidate. That means there’s disruption, but no guarantee it will prevent the creation or continuation of a monopoly.
For those looking to sell, I think they’re going to face increased transaction costs with any multimarket acquisition, along with a lot more deal uncertainty. But here’s the silver lining: If the divestiture trend holds true to its original intent, it will actually open up acquisition and partnership opportunities for independent physician-owned ASCs and smaller groups. The independents stand to gain strategic value as a competitive alternative.
To ensure that, we need differentiation on quality, innovation, and access — those become competitive advantages when scale is being scrutinized and constrained. Honestly, everybody can win from this — physicians, patients, payers, employers — because it could help accelerate the steerage of high-value ASCs in markets where competition is actually preserved. This brings into focus a really sharp new nuance in the path forward for the ASC shift. Hopefully it’s tied to better value and not just bigger footprints. As migration into the ASC space continues, this only reaffirms the importance of these strategic initiatives. Everybody is now waking up and recognizing that the ASC is the correct site of service — in perpetuity.
Bruce Feldman. Founder, ASC Consulting Firm and Former Administrator of Eastern Orange Ambulatory Surgery Center (Cornwall, N.Y.): I agree with the FTC’s consent order in the pending deal between Ascension and AmSurg, requiring Ascension to divest several ASCs from its proposed $3.9 billion acquisition of AmSurg. We need to avoid ASC management companies from creating a monopolistic environment using ASCs as a means to boost shareholder profits. Allowing companies such as this to greatly expand their footprint in the ASC arena will only drive up the cost of providing care in the ASC setting due to less competition in the ASC market, something which is directly contradictory to what ASCs are supposed to be about.
As ASC leaders, we need to make sure that ASCs continue to focus on providing high quality care in a lower cost setting. Lessons should be learned from companies such as Amazon now looking to get involved in the delivery of healthcare through the acquisition of insurance companies. Profitability is important but at what cost?
Nyleen Flores. Administrator and COO of Lake Oconee Orthopedics (Greensboro, Ga.): I support efforts to prevent anticompetitive behavior in healthcare. When mergers reduce competition, drive up costs, or limit patient choice, regulators have a responsibility to step in.
However, protecting competition is not the same as controlling ownership choices.
The FTC’s requirement that Ascension divest certain ASCs to preserve competition in specific markets is a reasonable antitrust remedy. Where I become concerned is when the broader conversation shifts toward determining who healthcare providers can and cannot partner with financially.
Physicians, ASCs, and healthcare organizations should have the freedom to pursue investment structures that support growth, innovation, and access to care, whether the partner is a health system, physician group, private equity firm, or another investor. The question should not be who owns it — the question should be whether it benefits patients, preserves competition, and delivers quality care.
There is a growing narrative that private equity involvement in healthcare is inherently problematic. The reality is more nuanced. Good outcomes and bad outcomes can occur under any ownership model. Ownership alone does not determine quality, governance and oversight do. A poorly governed hospital can create just as much risk as a poorly governed private-equity-backed ASC.
What matters is accountability, quality metrics, compliance, patient safety, and outcomes, not who wrote the investment check. If regulators are genuinely focused on preserving competition, scrutiny should be applied consistently across all forms of consolidation, including large health systems that continue to expand their influence over physician practices, outpatient facilities, and local healthcare markets. Competition is healthy. Oversight is necessary. Transparency is essential. But the goal of antitrust policy should be protecting competition and patients, not creating an environment where hospitals, health systems, or regulators effectively decide which types of investors are acceptable. Healthcare organizations should be judged by the care they provide, the quality they achieve, and the safeguards they maintain, not by the label attached to their ownership structure.
Jim Freund. Managing Partner of Physician Transaction Advisors: I certainly understand the importance of having competition in any market, so having oversight in this area is important. However, I do not understand why they oversaw the sale or transfer of almost all these centers to a single organization. At the same time, if the FTC is truly concerned about competition and cost, they should focus on eliminating the disparity between what hospitals and their HOPDs are being paid for procedures versus what ASCs are being paid for the same cases, while having greater patient and physician satisfaction scores. This would truly have a significant impact on the cost of delivering healthcare.
Sean Gipson. CEO and ASC Division President of Remedy Surgery Center (Houston):This a complex situation that I’ll try to put into a smaller explanation.
The FTC’s consent order in the Ascension-AmSurg deal is a fairly classic example of how the agency is using structural divestitures in concentrated outpatient care markets to “fix” a merger rather than block it outright, but it also signals how seriously the FTC is now treating ASC consolidation specifically.
The key insights and what they mean in practical terms are simple. The FTC is defining ASCs as highly localized monopoly markets. 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).
That matters because even if Ascension and AmSurg looks modest nationally, the FTC is effectively saying that the competition can be harmed in individual zip-code-level surgical markets, and a single deal can create pricing power in narrow outpatient service lines
The solution is creating an “overlap correction” rather than full merger rejection. The remedy shows the FTC is not trying to stop hospital systems from expanding into ASCs, but to preserve “pre-merger competition” in overlapping markets and prevent a local reduction in ASC operators from 3 to 2 or 2 to 1. This is important because the FTC is signaling that ASC consolidation is acceptable only if market structure is preserved at the local level. Essentially protecting the independent market in the area.
Seven divestitures show the acknowledgment of meaningful competitive clustering and requiring divestiture of seven centers across Nashville, Tulsa, Waco, Wichita, and Panama City suggests the agency identified multiple “high-risk” geographic clusters and did not isolated overlaps, but a pattern of regional market concentration.
From the antitrust side of things, this implies the FTC likely found systematic competitive overlap between AmSurg and Ascension’s existing or affiliated outpatient footprint and not just one-off concerns.
Buyer selection matters as much as divestiture itself. The order is also notable for who is buying. Most centers go to SC Affiliates (an experienced ASC operator) and one goes to a physician-owned gastroenterology group already partially invested. In my opinion, that reflects a broader FTC concern seen in recent cases and divestitures only preserve competition if the buyer is operationally credible. Otherwise, the remedy can fail in practice even if it looks clean on paper.
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. 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.
The remedy is a signal to the broader ASC market. Even though only seven centers are divested, the precedent matters more. Large ASC platforms should expect market-by-market scrutiny, deals that cross hospital systems and ASC operators will face localized divestiture demands and buyers in ASC roll-ups will need to demonstrate they can maintain independent operations post-close.
The bottom line is that this consent order shows the FTC is comfortable allowing ASC consolidation only when it can surgically reconstruct local competition through divestitures. It’s less about stopping consolidation outright and more about ensuring that outpatient surgical markets retain at least two to three viable independent operators per geography and service line.
Melissa Rice. Administrator of Loyola Ambulatory Surgery Center, Trinity Health (Maywood, Ill.): The FTC’s action really highlights how closely regulators are watching ASC consolidation at the local level — even for nonprofit systems. While growth and scale can bring benefits, these divestitures show there’s real concern about keeping enough competition in specialties like GI, ophthalmology, and ortho, where fewer options can quickly drive up costs and limit patient choice.
It’s also interesting that the deal can still move forward with some guardrails in place — like selling off select centers and adding long-term oversight. That 10-year lookback on future acquisitions in those markets is a big signal. For ASC leaders, it’s a reminder that growth strategies need to clearly show how they’ll maintain access, quality, and affordability — not just expand footprint.
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.