Merger enforcement in deals involving hospitals and ASCs is below average, according to a report released by the Progressive Policy Institute in December 2025.
The report evaluated 70 economic studies that analyzed the impacts of hospital acquisitions on physicians, patients and communities. It notes that trends in key metrics of federal enforcement represent growing concerns over “strategic anticompetitive conduct, changes in the regulatory environment, and advances in technology or business models.”
PPI analyzed merger enforcement statistics collected as a part of the Hart Scott Rodino Act requirements for hospital and ambulatory health services.
The analysis found that between 2017 and 2024, the rate of federal clearances for ASC and hospital transactions were 26% and 51%, respectively, far higher than the average of 13% across all sectors.
“This may signal the agencies’ intention to more intensely scrutinize mergers in these sectors,” the authors write.
Conversely, at the second request stage of mergers, the rate of second requests for ASCs and hospitals is lower than the all-sector average.
“This gap worsens for the rates at which the agencies challenge merger transactions as illegal,” reads the report. For ASCs, the challenge rate is eight times lower than average, and for hospitals, the rate is about five times lower than average. This signals that the FTC and Department of Justice approach consolidation involving hospitals and physician practices with more scrutiny in earlier stages, but back off in later-stage investigations that may lead to merger challenges.
Additionally, between 1990 to 2025, the FTC and state attorneys brought nine antitrust enforcement actions in cases involving hospital and physician practice mergers.
In an October 2025 report, The Private Equity Stakeholder project found that private equity-backed “roll-up” strategies in ASC deals have helped create some of the country’s largest platforms, often through a series of smaller acquisitions that do not always trigger federal enforcement action or oversight.
Some of these platforms are now being purchased by large nonprofit health systems, sparking renewed scrutiny as to whether consolidation in the ASC market is expanding in ways that may have an unforetold ripple effect on the industry, according to PESP.
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.
