When Ascension completed its $3.9 billion acquisition of AmSurg on June 4, it marked the end of a three-decade arc for one of the most consequential companies in ASCs.
AmSurg controls roughly 3.9% of the ASC market with 250-plus centers across 34 states and partners with about 2,000 physicians. That platform, built over 30 years through physician partnerships, a private equity leveraged buyout, a bankruptcy and a post-bankruptcy rebuild, now sits inside a nonprofit Catholic health system that had 58 ASCs a year ago. Ascension itself went from running 139 hospitals in 2022 to operating 90 hospitals and more than 300 ASCs by June 2026.
That transformation is a signal about where the entire market is headed.
The land grab is accelerating
Dallas-based Tenet Healthcare deployed $125 million in the first quarter of 2026 to acquire seven ASCs, representing half of its $250 million annual M&A target for USPI, which now operates nearly 570 assets. USPI, SCA Health and Surgery Partners are all acquiring aggressively, and the window to acquire for mature, independently owned ASCs may be closing.
Ascension President Eduardo Conrado told Becker’s the outpatient segment is growing 9% to 12% over the next five years. Every major platform is trying to capture as much of that growth as possible before the market consolidates further. The acquirers with scale have a structural advantage in payer negotiations, technology investment and physician recruiting that grows wider with each transaction.
What the FTC’s intervention signals
The Ascension-AmSurg deal did not close cleanly. The Federal Trade Commission required seven divestitures across five states before approving the transaction, which is the first time federal regulators applied that level of scrutiny to an ASC-specific deal. The consent order requires Ascension to provide prior notice before acquiring any ASCs in the affected metropolitan areas for 10 years.
The FTC’s framework was explicitly local. That standard has direct implications for any operator building density in a single market.
“The FTC is defining ASCs as highly localized monopoly markets,” Sean Gipson, CEO and ASC division president of Houston-based Remedy Surgery Center, told Becker’s. “Competition is not national or even statewide — it is metro-area specific and service-line specific.”
Private equity-backed roll-up strategies have helped build some of the largest ASC platforms through a series of smaller acquisitions that may not individually trigger federal reporting requirements. By the time a larger acquisition takes place, policymakers may be reviewing a transaction in a market that has already shifted substantially, according to a report from the Private Equity Stakeholder Project.
That local-market framing is significant beyond this transaction. In an analysis of the order, law firm Akerman said the case reinforces a long-standing FTC enforcement theme of healthcare antitrust analysis that remains local even when the parties operate nationally, making targeted divestitures and ongoing oversight a recurring feature of merger review.
The consent order could be a signal that the methodology of consolidation is now under scrutiny, and that future megadeals will require geographic overlap analysis earlier and more rigorously than before.
Not every independent ASC operator is looking at these deals and seeing an exit. A VMG Health survey found that 59% of independent ASCs would consider a strategic partnership rather than a full transaction. Among those open to partnerships, 71% said they would consider partnering with a health system, while 31% would consider a management company and 29% a private equity group.
Physician-owned ASCs that have built their identity around clinical autonomy and local relationships are not natural fits for absorption into a national platform. What they are increasingly open to is capital, payer contracting leverage and administrative infrastructure without surrendering governance.
“The days of physicians being seen as widgets to be monetized are over, and hospitals and health systems know this,” Peter Doble, MD, and Heath Veuleman, formerly of Sawtooth Surgery Center in Twin Falls, Idaho, told Becker’s. “As care becomes consumer-centric and ambulatory-centric, hospitals and health systems must become shareholders in physician-led enterprises to still maintain market share.”
More than 60% of hospitals and health systems report that payers are pressuring them toward ASC options for appropriate cases, according to Avanza’s Intelligence Hospital Leadership ASC Survey. Twenty-five percent of surveyed hospitals said they are expanding their ASC footprint specifically due to payer pressure.
The Ascension-AmSurg transaction removed one of the industry’s largest independent-adjacent platforms from the available acquisition market and put it inside a health system. That changes the competitive landscape for every operator in the 34 states where AmSurg was previously a partner or competitor.
Jim Freund, managing partner of Physician Transaction Advisors, raised a related concern about buyer concentration.
“I do not understand why they oversaw the sale or transfer of almost all these centers to a single organization,” he said. “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.”
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.