Private equity-backed “roll-up” strategies in ASCs have helped create some of the country’s largest platforms, often through a series of smaller acquisitions that may not individually trigger federal antitrust reporting requirements, according to a recent report from the Private Equity Stakeholder Project.
Now, some of those platforms are being purchased by large nonprofit health systems, raising new questions about whether consolidation in the ASC market is accumulating in ways that are difficult to evaluate until the industry has already shifted, the project alleges.
Health systems and hospitals are looking to expand their ASC footprint. In a 2025 VMG Health survey of health system executives, including CEOs, CFOs and COOs, outpatient surgery ranked as the top service line for joint venture partnerships, with more than 60% of respondents indicating ASCs were a top interest for their growth.
Other major ASC groups’ strategy is rooted in acquisition. In 2015, Tenet Healthcare purchased 50.1% of Dallas-based United Surgical Partners International for $425 million. USPI has since grown to the largest ASC chain in the country, with ownership interests in 530 ASCs (with 398 consolidated) and 26 surgical hospitals (with eight consolidated) across 37 states.
Deerfield, Ill.-based SCA Health, formerly known as Surgical Care Affiliates, was acquired by UnitedHealth Group’s Optum in 2017 for $2.3 billion. As of late 2024, SCA Health now has 423 ASCs.
A roll-up strategy typically involves building a large platform through the acquisition of multiple smaller businesses, often in fragmented markets. Some industry observers allege that because smaller deals may fall below reporting thresholds, consolidation can build incrementally with limited visibility to regulators. By the time a larger acquisition takes place, policymakers may be reviewing a transaction in a market that has already changed substantially.
“Many economically important industries are highly segmented, meaning each consumer is served by a small number of producers. In these cases, even minor mergers can produce major changes in market structure, competition, price, and quality,” according to a 2023 article by Chicago Booth Review. “Anticompetitive mergers that would otherwise be blocked or deterred by the federal government may instead escape antitrust scrutiny by simply falling below reporting thresholds.”
Supporters of roll-ups counter that ASC consolidation can improve access, standardize quality and bring operational resources that independent sites may not have, particularly as case complexity rises and staffing challenges persist.
“The pros include the provisions of large capital injections enabling ASCs to grow and expand facilities, acquire advanced equipment and implement technology to enhance operational efficiency,” Sean Gipson, division CEO and president of Remedy Surgery Center, told Becker’s. “PE backing can potentially open doors for new locations, form strategic partnerships and pursue mergers/acquisitions to compete more aggressively with their larger groups.”
A recent example of how these roll-ups can provide scale quickly is Ascension’s announcement of its acquisition of AmSurg.
AmSurg was once one of the largest standalone operator of ASCs in the U.S. In 2016, AmSurg merged with Envision Healthcare in a $10 billion all-stock deal, creating a larger healthcare services company spanning ASCs and physician services.
In 2018, private equity firm KKR acquired the combined company in a $9.9 billion leveraged buyout financed with more than $7 billion in debt, a transaction structure that is common in large buyouts but can create long-term financial obligations, according to the PE Stakeholders report.
In May 2023, Envision filed for Chapter 11 bankruptcy protection, citing pressures that included rising interest rates, labor costs and payment disputes with insurers. As part of the restructuring, AmSurg ultimately purchased the ASCs held by Envision.
By the time Ascension made its bid for AmSurg, its owners included several investment firms, including King Street Capital Management, Pacific Investment Management, Partners Group and Columbus Hill Management.
In June 2025, Ascension announced it had acquired AmSurg for roughly $3.9 billion, bringing more than 250 ASCs that AmSurg manages across 34 states under the nonprofit system’s umbrella.
“While the journey is never finished, I am confident we have significantly strengthened our capabilities,” AmSurg CEO Jeff Snodgrass told Becker’s. “The Ascension acquisition provides an opportunity to continue building on this work. Our operating and partnership model has always been built on what we term the ‘collaborative model’ — the acquisition will not change that.”
According to the Private Equity Stakeholder report, this type of acquisition, where a platform is built over time through a large number of smaller acquisitions before being purchased in a major transaction, illustrates why regulators are increasingly focused on “serial” or “stepwise” consolidation.
Another example of this type of deal is the Federal Trade Commission’s lawsuit against Welsh Carson, which was tied up in a lawsuit alongside its portfolio company, U.S. Anesthesia Partners. The lawsuit, which was settled in May, alleged the two companies executed an anticompetitive scheme to consolidate anesthesiology practices in Texas, drive up the price of services and boost their profits. The FTC claimed that Welsh Carson executed a roll-up scheme, buying up almost every large anesthesia practice in Texas to create a single, dominant provider that could demand higher prices.
In January, the FTC reached a settlement with Welsh Carson, requiring the company to limit its involvement with USAP and notify the FTC of specified future acquisitions and investments in anesthesia and other hospital-based physician practices.
The core concern raised by some experts isn’t necessarily the single transaction itself, but whether cumulative market power can build through many smaller transactions that don’t receive the same level of review as a major merger.
“By purchasing a large operator shaped by private equity financing, Ascension is able to accelerate its growth while inheriting a network assembled largely below the radar of traditional antitrust enforcement,” the Private Equity Stakeholder report said. “Although Ascension’s AmSurg purchase was large enough to trigger antitrust review, much of the network had already been built through smaller deals that drew little scrutiny. Roll-up consolidation strategies such as this allow market power to accumulate through small transactions that fall below antitrust reporting thresholds.”
At the same time, health systems pursuing large-scale ASC acquisitions say that owning or partnering with outpatient surgery sites is becoming critical as healthcare shifts away from inpatient settings, payers steer procedures to lower-cost sites and physicians increasingly seek aligned ambulatory infrastructure.
“We truly think this AmSurg partnership will be transformational for our organization,” said Amber Sims, executive vice president and chief strategy and growth officer at Ascension, during a Nov. 3 panel at Becker’s CEO and CFO Roundtable in Chicago. “We recognized that we have to get ahead in the ambulatory business, because that’s where care is going. It’s where patients want to receive care, where payers want to seek care, and where providers want to provide care.”
