ASCs are here to stay as an increasingly central pillar in the U.S. healthcare system.
In its annual report to Congress released March 12, the Medicare Payment Advisory Commission found that the number of ASCs nationwide grew more than 2% per year on average between 2019 and 2024, and the volume of ASC surgical procedures per fee-for-service beneficiary increased 3.5% in 2024 alone, after growing at an average annual rate of 1.3% from 2019 to 2023.
As the industry continues to expand, several stakeholders have emerged with the upper hand in a rapidly changing space.
Hospitals and health systems
An ambulatory boom has been making its way through hospitals and health systems over the last several years, with no signs of slowing down.
Outpatient care volumes are expected to rise by 18% over the next decade, while inpatient care will see a more modest growth rate of 5%, according to a June 2025 forecasting report from Sg2. Inpatient acuity, however, is expected to rise and many health systems are already seeing this shift play out.
“We are beginning to see changes in our case mix index in the inpatient world, implying that we are treating sicker patients in the process,” Todd Smith, MD, chief physician executive at Sacramento, Calif.-based Sutter Health, said in an interview for the “Becker’s Clinical Leadership Podcast.”
ASCs may also play a critical role in improving access to surgical services, a key point of many health systems’ missions over the next decade.
“All of our length-of-stay initiatives are making sure that patients are getting the quality care that they need when they’re in the hospital,” Samuel Bauer, MD, a maternal fetal medicine specialist and chief medical officer of Corewell Health William Beaumont University Hospital in Royal Oak, Mich., told Becker’s. “And if there are certain things that they don’t need [to be done] in the hospital anymore, that can be done in the outpatient setting, that can be more nimble … lots of initiatives around length of stay helps not only with cost, but it certainly helps with quality for our patients.”
Entrepreneurial physicians
The relatively fragmented ASC market presents new opportunities for physicians looking to step away from traditional employment models and take their practice independent — often through a new array of hybrid ownership models, joint ventures and management services agreements.
“Protecting each physician’s identity in the group is strategic. When physicians feel like stakeholders, they stay engaged in building referral networks, driving volume and maintaining subspecialty excellence,” Justin Tricax, MD, a cardiologist with Millennium Cardiology in Farmington Hills, Mich., told Becker’s.
Perhaps more significant is the connection between physician identity and autonomy and the sustainability of the practice, he added.
“That engagement is what creates real leverage within a large organization,” Dr. Trivax said. “Without it, productivity becomes transactional and one’s influence can erode quickly. At the same time, autonomy only holds if it is actively used. Referral control, procedural volume, and expertise give the group negotiating power, but only if physicians are involved in decisions that shape those areas. The leadership move is to connect identity to influence, making it clear that clinical ownership and engagement are what preserve operational independence within the system.”
According to a 2024 survey by Bain & Co., 81% of physicians working in physician-led organizations reported satisfaction with their involvement in strategic decision-making, compared with just 50% in hospital-led practices.
Commercial payers — but often at ASCs’ expense
A major component of ASCs’ value proposition is their ability to perform the same surgical procedures as a hospital outpatient department at a lower cost — and payers are starting to catch on.
Commercial insurers paid an average of $1,489 more for common procedures at HOPDs than at ASCs in 2024, a 78% mark-up, according to a study published in Health Affairs. Medicare also paid more when those procedures were performed in HOPDs, but the difference was smaller in dollars: $633 more per case, a 97% mark-up. Among the commercial payers, Cigna had the narrowest gap, at $327.
For hip and knee arthroplasty procedures performed in ASCs, Medicare professional fees for surgeons declined from 2018 to 2024, even after adjusting for inflation, according to a July 2025 report on Science Direct. Over that period, unicompartmental knee arthroplasty professional fees fell from about $1,487 to around $1,148.
Despite the lower cost of these procedures, ASCs still find themselves in precarious financial positions as a result of payer contracting issues and reimbursement declines.
ASC leaders describe a landscape in which insurers are flexing scale, data analytics and network design to contain costs and steer volume, while centers counter with outcomes data, operational discipline and lower total cost of care. At the same time, high-performing ASCs argue that predictable throughput, surgeon alignment and measurable quality outcomes can shift the leverage calculus, particularly in markets where they are essential network partners.
“This is a genuinely dynamic negotiation landscape right now, and pretending it’s one-sided in either direction does a disservice to the complexity,” David Jeversar, MD, CEO of North Chesterfield, Va.-based OrthoVirginia, told Becker’s.
“Where payers are gaining ground: Data asymmetry remains the single greatest advantage payers hold. They understand utilization patterns, cost benchmarks and claims trends far better than most ASCs do. When a payer walks into a contract negotiation with claims analytics and a facility walks in with a spreadsheet, the outcome is predictable,” he continued. “Payers are also leveraging narrow network construction aggressively — particularly in markets with multiple competing ASC options — using the credible threat of exclusion to suppress rates. Tiered networks and reference-based pricing models are additional tools payers are deploying to commoditize surgical facilities.”
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.