The ASC industry has been steadily growing throughout 2025, with at least 74 ASCs announced, completed or constructed in the first half of the year alone.
While the industry overall is projected to experience further expansion and growth over the next several years, it also faces significant labor, cost and regulatory challenges.
Good news
1. Certificate-of-need updates: Several recent updates point to increased support in several states for the repeal of certificate-of-need laws, which critics claim have long-stifled healthcare competition, especially in the ASC space
In North Carolina, for example, an ophthalmologist has been embroiled in a five-year-long legal fight against the state laws, which he claims are unconstitutional. The lawsuit has sparked discussion among lawyers and healthcare professionals in the state, who say that the law’s repeal could spark new competition between rival healthcare systems in the region.
North Carolina is already on track to eliminate its CON laws by January 2026. As an interim measure, since Nov. 1, 2023, ASCs in counties with populations over 125,000 have been exempt from CON approval, already spurring new facility development in high-demand regions.
North Carolina is one of seven states that have been re-evaluating its CON laws in recent years. Montana repealed its CON law in 2021, and has seen a 12.5% increase in the number of ASCs, home health agencies and inpatient addiction treatment centers as a result. According to an October report by the Frontier Institute, the repeal has lessened the barrier to entry for providers in the state, and has already increased patient access to same-day surgical care, especially in rural areas that previously lacked these facilities.
2. Continued procedure migration: In July, CMS proposed more than 200 procedures for removal from the inpatient-only list and addition to the ASC Covered Procedures List.
“The shift from inpatient to outpatient is the dominant trend in modern healthcare — but it’s unevenly distributed,” Scott Becker, JD, Founder and Chief Content Officer, Becker’s Healthcare; Partner, McGuireWoods LLP, said at Becker’s 31st Annual ASC Conference. “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.”
In its “ASC Leader Expectations for 2026” survey, VMG Health found that leaders are most closely looking towards spine, total joint replacements and cardiology as service line investments — all of which were highlighted by CMS’ July announcement.
3. New formats for joint ventures, collaborative development: While many ASCs remain independent, the growing presence of hospitals, health systems and corporate entities in the ASC space has heated up competition and made negotiations with private payers more challenging for independent practices.
As a result, a new wave of management services organizations, joint venture platforms and other independence-minded entities have begun rolling out new ASC ownership models that give ASCs access to shared resources and financial support while maintaining their autonomy.
Most recently, Becker’s reported on NueHealth, an ASC management company that positions itself as an adaptable, physician-centric organization built for the next phase of outpatient care. The company has developed, managed or owned more than 150 facilities and partnered with over 3,000 physicians and 30 health systems. A major part of its competitive edge, CEO Michael Sheerin told Becker’s, is that NueHealth has remained privately held. This structure allows leadership to invest in initiatives that may not generate immediate returns but create long-term clinical and operational value.
Hospitals and health systems are also increasingly interested in partnering with ASCs, finding arrangements that give ASC teams autonomy and access to shared resources while generating revenue for the hospital.
“It’s not a ‘them versus us’ mentality anymore,” Karen Reiter, vice president of operations and payer management at Newport Beach, Calif.-based TriasMD and DISC Surgery Centers, told Becker’s. “This ongoing collaboration is a great thing to see and will take us where we want to go.”
Bad news
1. CMS’ Physician Fee Schedule: On Oct. 31, CMS issued its final policy changes for Medicare payments under the Physician Fee Schedule, The conversion factor for practitioners participating in a qualified alternative payment model is $33.56, a 3.77% increase from 2025.
The American Medical Association issued a statement Nov. 2 cautioning that although CMS’ final rule “includes a vital, one-time 2.5% update and critical telehealth provisions, other components of the rule may have unintended consequences for patients and private physician practices across the country.”
“That physicians are not facing a reduction in reimbursements — as we have in the past — is a significant positive for 2026 and a win for patients’ access to care. Yet, this one-time correction does not keep up with increasing costs, and private practices across the country are expressing concern this rule would further put them at a disadvantage merely for treating patients at a hospital or ambulatory surgery center,” AMA President Bobby Mukkamala, MD, said in the statement. “As the new rule is implemented and its changes are felt, we will share with CMS the real-world impacts — data and details not always easily available to policymakers in Washington. This exchange and collaboration are vital to keeping practices open during a physician shortage.”
2. Rising costs of operations: When asked what operational hurdles they were most heavily anticipating in 2026, 72% of ASC leaders told VMG Health that expenses related to operations, supplies and wages was their chief concern.
Healthcare costs for commercial payers are projected to increase by up to 8.5% in 2026, driven by persistent inflation, rising utilization of behavioral health services, and escalating prescription drug spending, according to a new report from PwC’s Health Research Institute.
Howard Mitz, DO, gastroenterologist and owner of Littleton, N.H.-based North Country Gastroenterology, told Becker’s that reimbursement rates are failing to keep pace with expenses.
Dr. Mitz said the biggest financial strain on his practice stems from “insurance companies not keeping up with the rising costs of everything,” from IV solutions and infusions to staff salaries.
3. Anesthesia shortages: The ongoing shortage of anesthesia providers in the U.S. as well as their increasing compensation demands continues to be a major issue for ASC leaders in 2025. In the VMG Health survey, 58% of leaders listed anesthesia as their number one concern.
CMS’ 2025 anesthesia conversion factor decreased by 2.20%, continuing a multiyear erosion of reimbursement that has reduced average anesthesia payment from $22.27 per unit in 2019 to $20.44 in 2024.
Recent projections indicate that by 2036, the country will be short 6,300 anesthesiologists, and 56.9% of currently practicing anesthesiologists are already over age 55.
Without restructuring, anesthesia groups will likely struggle to fill staffing gaps, maintain OR coverage and support expanding ASC case volumes.
“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.”
