Ambulatory surgery centers have become one of the most dynamic — and pressured — segments of healthcare.
At Becker’s 31st Annual ASC Conference, Scott Becker, JD, Founder and Chief Content Officer, Becker’s Healthcare; Partner, McGuireWoods LLP, offered a candid look at where the industry stands today, what forces are reshaping it, and how leaders can navigate the next phase of growth. His remarks captured both the promise and the tension defining ASCs in 2025 — a sector marked by expansion, consolidation, and the constant need to adapt in an increasingly complex healthcare landscape.
Here are 20 key points:
1. There are roughly 6,400 Medicare-certified ASCs nationwide, plus several thousand additional non-Medicare centers — often focused on plastics, ophthalmology, and other cash-pay specialties.
2. About half of ASCs now have a hospital or management company partner, or both. Independent centers remain crucial but are increasingly outnumbered.
“The freestanding surgery center is highly dependent upon the independent surgeon — and that’s the real challenge,” said Mr. Becker. “We haven’t seen a surge in new independent surgeons for years, and most who are independent are already tied to an ASC. So the question isn’t whether outpatient surgery is growing — it clearly is — but whether there will be enough independent physicians left to sustain that growth. The business model relies on people who are becoming rarer every year.”
3. Orthopedics, ophthalmology, gastroenterology, and pain management remain the top specialties, though others are gaining traction. Within these ASCs, the “beachhead” model works. The best ASCs often anchor around one to three core specialties and have a strong beachhead group that defines excellence and drives growth.
4. Staffing shortages and escalating costs for labor, supplies, and equipment. Anesthesia is especially challenging for centers today.
“We’ve reached a point where the staffing costs — including anesthesia — are rising faster than reimbursement,” said Mr. Becker. “It’s not that the ASC model doesn’t work; it’s that the math has changed. When anesthesia coverage becomes a premium expense, even a well-run center feels the pressure.”
5. The steady shift continues toward outpatient settings for total joints, spine, vascular access, and more. Some cases migrate to ASCs, others to hospital outpatient departments. But the shift isn’t the same everywhere. Outpatient migration is state-dependent, with commercial insurers in some states open to spine and orthopedic centers while payers in other states won’t approve the procedures outside of hospitals, and that shapes the growth trajectory for the ASC market.
“The shift from inpatient to outpatient is the dominant trend in modern healthcare — but it’s unevenly distributed,” said Mr. Becker. “For some ASCs, it’s been a windfall; for others, it’s been neutral or even negative. The success stories are the centers positioned to take advantage of the migration, not just watch it happen.”
6. Physician shortages loom large. There are roughly 1.1 million physicians serving 345 million people in the U.S. Access challenges are growing even as coverage expands. The nation faces a shortage in key specialties, an aging physician workforce, and rising demand — especially as concierge and limited-panel practices expand.
7. Independent surgeons matter. Independent physicians remain the lifeblood of many successful ASCs. Their engagement drives both case volume and culture.
“In the past, surgeons made a disproportionate share of their income from their surgery centers. That’s no longer the case,” said Mr. Becker. “The excess profits have been squeezed out by payer consolidation, the No Surprises Act, and changes in reimbursement. So while ASCs remain vital to physicians, they’re no longer the windfall that drives wealth — they’re just one more part of a harder, more balanced business equation.”
8. The ‘build it and they will come’ era is over. Growth must be earned through alignment, physician partnership and performance. “What you’re seeing is consolidation — fewer, stronger centers doing more cases. The big, successful ASCs become magnets that absorb volume from smaller, struggling centers,” said Mr. Becker.
9. The imbalance between payers and ASCs continues to widen. Reimbursement pressure remains one of the greatest strategic risks for surgery centers.
“We used to think the perfect ASC market had five or six payers, none dominant,” said Mr. Becker. “Now, in almost every state, one payer controls the market. That imbalance changes everything — it makes negotiation nearly impossible. If you’re not in-network with that payer, you’re essentially shut out of the market. The result is that independent providers are price-takers in a system where they used to have leverage.”
10. The power of the giants. UnitedHealth Group and CVS Health rank among the six largest companies in America, behind only Walmart and Amazon. Their scale gives them enormous influence over care delivery and contracting. Elevance and Cigna are also in the top 20 U.S. corporations by revenue — further consolidating payer power.
“Medicare Advantage has become a double-edged sword. It was supposed to bring efficiency and competition, but in reality, it handed control of half of Medicare to commercial insurers,” said Mr. Becker. “Providers now face the worst of both worlds — government-level reimbursement tied to private-level bureaucracy. The result is lower payments, higher administrative burden, and less flexibility for surgery centers.”
11. ASC chains vs. payors. The five major ASC chains — USPI, SCA Health (Optum), Amsurg (Ascension), HCA Healthcare, and Surgery Partners — wield significant influence, but their market power still pales next to the payers they negotiate with.
12. Private equity influence is growing. Private equity now owns roughly 8.5% of U.S. hospitals and 6.5% of physician groups, helping fuel consolidation but also capitalizing on operational efficiency.
“Private equity has become an easy target politically, but it’s not the core problem in healthcare,” said Mr. Becker. “For many practices, it’s just a mechanism to handle the complexity — access to capital, revenue cycle sophistication, growth. The issue isn’t private equity itself; it’s what kind of business you put debt on.”
13. Site-of-service disparities persist. Payment differentials between hospital outpatient departments and ASCs remain a challenge. Reform here is key to fair competition.
“It makes no sense that surgery centers get paid half of what hospitals get for the same procedure,” said Mr. Becker. “But it also reflects a deeper truth — hospitals are still part of the country’s safety net. The payment system isn’t rational; it’s a patchwork that props up hospitals so the system doesn’t collapse. The ASC leader’s challenge is to thrive within that irrational system while hospitals remain politically untouchable.”
14. Case migration to the outpatient setting continues — but limits remain. CMS’s inpatient-only list still constrains what can move outpatient, though momentum toward site-neutral care keeps building.
“You have to look at where the cases are going, not just that they’re leaving the hospital. If your market allows outpatient spine or total joints, that’s your opportunity,” said Mr. Becker. “If it doesn’t, you have to adapt — the migration trend is real, but how much of it you capture depends entirely on your contracts and specialties.”
15. Leadership matters. Great ASCs rely on exceptional physician, administrative, and clinical leaders. Culture, alignment, and daily execution separate the best from the rest.
“A great physician leader is someone who’s productive, respected, and a bit of a team player — not somebody who dominates through ego,” said Mr. Becker. “The ASC model depends on collaboration more than hierarchy. You can’t run a center like a private practice; you have to lead like a business partner.”
16. Centers must be big enough to support depth and expertise — finance, compliance, recruiting — but nimble enough to stay entrepreneurial. Leaders have to understand their strategic advantage and how to make the most of their place in the market.
“Leadership isn’t just about running a center — it’s about positioning it,” said Mr. Becker. “You have to be large enough and well-led enough to have leverage with payers and partners. Without that organizational leadership and alignment, you’re a small boat in a big ocean.”
17. Payer negotiation power. To survive, ASCs need enough local or regional scale to wield influence with payers. Lone centers face steep odds, especially as payers change the rules. Prior authorizations, denials and revenue cycle friction are a way to suppress payments and stymie collections.
“You almost always have to be big enough today to have some power with the payers in your community. The best situations are mid-sized towns with a dominant orthopedic or GI group. When the payer can’t go around that group, you finally have leverage again,” said Mr. Becker. He later noted, “Negotiating power used to come from relationships and out-of-network leverage. That’s gone. Now it’s about size, efficiency, and data — the ability to prove value and outcomes. Without that, you’re just a small player asking a $400 billion company for mercy.”
18. Expanding coverage doesn’t guarantee more access to care. The true constraint in U.S. healthcare remains supply versus demand — particularly for physicians, nurses, and anesthesia providers.
“Anesthesia is one example of the broader supply and demand crisis,” said Mr. Becker. “We’ve expanded the number of surgery sites but not the clinician base to match. The result is a bottleneck — not from patient demand, but from workforce capacity.”
19. Anesthesia shortages. In some areas, anesthesia is a crisis while others find it manageable. But every ASC leader is feeling budget pinches and even a one-day gap in anesthesia coverage means cancelled cases and lost revenue.
“It’s gotten to the point where anesthesia coverage is a competitive advantage. If you can reliably staff anesthesia, you can run full schedules and take volume other centers can’t. It’s become one of the defining operational challenges for ASCs today,” said Mr. Becker.
20. Increased complexity in business and regulatory management. “Most of the challenges in healthcare — access, burnout, quality — all come back to supply and demand. You can promise coverage for everyone, but without enough doctors and nurses, that’s like writing a check you can’t cash,” Mr. Becker said. “We’ve built a system that focuses on policy ideals rather than the math of workforce capacity. Until we fix that, every other solution is a patch, not a fix.”
