Private equity (PE) firms are rapidly buying up ambulatory surgical centers (ASCs) and reshaping US surgical care in the process.

According to a new report from the Private Equity Stakeholder Project, a watchdog group that monitors PE across multiple industries, investors are quietly consolidating outpatient surgery market share until they’re ready to sell. Exits are just beginning, but early deals suggest healthcare giants looking to vertically integrate are willing to pay vast sums to acquire PE-built ASC groups.

Meanwhile, patients — and even regulators — are often left unaware.

The report’s authors argue that greater transparency and stronger oversight are essential to ensure that patient interests aren’t overshadowed by profit.

A Fragmented, High-Value Market Draws Investors

In 2024, ASCs managed more than half of all outpatient procedural care and earned $45 billion in revenue, according to Colliers’ Q3 2025 Healthcare Services report. That number is expected to climb to $57 billion by 2030.

According to the Private Equity Stakeholder Project’s new report, the fragmented, in-demand, and profitable nature of the ASC sector makes it a natural fit for PE, which has invested more than $1 trillion in US healthcare over the past decade.

While ASC deal volume dropped significantly in early 2025 due to high interest rates — down about 50% compared with the previous 2 years — based on data from Levin Associates, market analysts note that smaller-scale consolidation never really stopped. Deals with independent practices and joint ventures are still happening; they’re just not publicly reported.

Consolidation Under the Radar

These small, quiet transactions receive little scrutiny yet serve as a driving force behind ASCs’ rapid consolidation.

“We’re trying to bring more attention to private equity in the outpatient setting, especially because private equity firms are consolidating outpatient clinics beneath the radar of a lot of regulators,” said Michael Fenne, senior policy coordinator at the Private Equity Stakeholder Project and author of the new report.

By the time firms are ready to exit, the group of ASCs offers hospitals and corporations considerable market power. Although these large transactions trigger antitrust review, regulators are often notified only after the consolidation has already happened, the report notes.

Examples of Quiet Growth Before Major Acquisitions

In June 2025, for instance, Ascension — one of the country’s largest nonprofit health systems — purchased ASC giant AmSurg for $3.9 billion. But AmSurg already had grown for nearly a decade under a rotating cast of investment firms.

Similarly, UnitedHealth Group’s subsidiary, Optum, has repeatedly acquired ASC chains expanded by PE. The insurer now owns at least 423 ASC facilities, according to Becker’s Payer Issues.

To Fenne, the consolidation trend is largely unknown to patients. “It’s surprising that even when there are requirements that these transactions be disclosed to regulators, that information may not make it to the public,” he said.

Why Physicians and Patients Should Care

It can be in patients’ and the public’s best interest to know if PE owns their surgery center, Fenne told Medscape Medical News. Unlike other types of investors, PE firms tend to take a highly active role in the management of the ASCs they acquire.

The firm “doesn’t just sort of take a back seat to the way the practices or the ASC is run,” said Erin Fuse Brown, JD, health law expert at the Brown University School of Public Health, Providence, Rhode Island.

“It’s not free money. It comes with some significant conditions, and the conditions often are total financial control. And that means, often, clinical control.”

Beyond billing and collections, PE firms may influence protocols, vendors, electronic health record systems, financial targets, staffing, and scheduling. Signing these contracts can cost clinicians some degree of autonomy, Fuse Brown said.

Earlier this year, the Cleveland Clinic gave daily operating control of ASCs to Regent Surgical Health, a management company backed by PE firm TowerBrook. Under the joint venture, the two entities will develop and manage new centers under the Cleveland Clinic brand — but Regent will handle day-to-day decision-making.

The announcement followed another Regent partnership with Mass General Brigham to expand its ambulatory surgical procedures. That same month, Mass General announced the largest layoffs in history.

Supporters Say PE Brings Efficiency — Critics Cite Risks

PE’s primary motivation in assuming operational control is cost cutting, Fuse Brown said. Supporters argue that a management and strategy overhaul — combined with an infusion of capital — can benefit struggling businesses.

“Sometimes the private equity funds are really good at picking management, understanding the business they’re in, understanding what makes a difference and what doesn’t,” said Scott Becker, JD, partner in McGuireWoods’ Healthcare Department, who represents both ASC chains and PE funds.

But critics say the short-term pursuit of high returns can undermine long-term care.

Evidence of Higher Costs and Workforce Strain

A 2023 systematic review published in the British Medical Journal found that PE investment across multiple healthcare sectors consistently led to increased costs for patients and payers. Another study in the Journal of Health Economics focused on ASCs found that while PE ownership didn’t increase surgical volume, it did drive up patient costs — procedures were, on average, 50% more expensive.

Physicians also may feel the impact. One 2023 study found that PE acquisitions were followed by physician turnover and a shift toward greater use of advanced practice providers.

It’s less clear if PE investment harms ASC quality of care, Fuse Brown said. But even if quality remains the same, the price hikes mean patients are paying more for the same care — therefore, losing value — when PE moves in, she said.

Becker said it’s impossible to write off all PE healthcare investors as either good or bad. The sector has “exploded to more than 18,000 private equity funds,” he told Medscape Medical News.

And, despite their growth, UnitedHealth still employs more physicians — about 10% of all US doctors — than all PE firms combined (6.5%), he said, referencing a 2024 presentation by United’s CEO and an analysis by the American Medical Association, respectively.

Calls for Stronger Oversight

The report authors argue that PE’s role in outpatient surgery requires stronger oversight. A 2024 Health Affairs policy analysis reached a similar conclusion, calling for policymakers to lower reporting thresholds, establish minimum staffing ratios and spending floors, and limit layoffs and post-acquisition real estate sales (forms of “asset stripping”).

Some states — including Massachusetts, Indiana, and California — have begun implementing such policies, and others are developing them, Fenne said. “It’s going to take a broader movement of policymakers, physicians, and patient communities because the private equity industry is so large and well resourced.”

Donavyn Coffey is a Kentucky-based journalist reporting on healthcare, the environment, and anything that affects the way we eat. She has a master’s degree from New York University’s Arthur L. Carter Journalism Institute, New York City, and a master’s in molecular nutrition from Aarhus University in Aarhus, Denmark. You can see more of her work in WIRED, Teen Vogue, Offrange, and elsewhere.