As the ASC industry continues to evolve, major players are adapting their strategies to meet market demands, regulatory changes and shifting patient needs.
Three of the largest ASC operators — United Surgical Partners International, HCA Healthcare and Surgery Partners — have made significant investments in expanding their networks, focusing on high-acuity procedures and navigating regulatory landscapes.
Here is how the strategy of each is shifting:
United Surgical Partners International
USPI’s parent company, Dallas-based Tenet, has reshaped its business model in recent years to focus on its surgery center arm. USPI remains the largest ASC operator, holding an 8.1% share of the ASC market. It has interests in 518 ASCs (375 consolidated) and 25 surgical hospitals (seven consolidated) across 37 states.
As part of this shift, USPI is exploring opportunities to “migrate certain lower-acuity, higher-volume types of activities out of the ASCs,” Tenet Healthcare CEO Saum Sutaria, MD, said in a recent earnings call. This strategic focus on high-acuity procedures aligns with an industry-wide trend of migrating services such as cardiology, orthopedics, and advanced spine procedures from hospital settings to ASCs.
In 2024, Tenet sold 14 hospitals across California, South Carolina and Alabama for more than $4.8 billion. Tenet plans to invest $250 million annually in ambulatory mergers and acquisitions, reinforcing its position as the largest ASC operator in the U.S. USPI also added nearly 70 ASCs, maintaining an aggressive approach to mergers, acquisitions, and de novo developments.
In 2025, the company plans to add 10 to 12 de novo centers. Tenet Executive Vice President and CFO Sun Park said in the call that de novo development is “really critical” for USPI and that the company has been focusing on scaling up this area.
“Consistent with our move into more high-acuity ambulatory surgical work, de novos also represent a significant value shift in markets, because usually what you’re doing is building from the ground up,” he said. “You’re moving things into a lower-cost setting. It’s value for the consumers and payers in the markets to be focused on de novos, in addition to everything else that we may be doing to grow the portfolio and expand the high-acuity services, so that it’s part of our value strategy there.”
Additionally, while USPI continues to prioritize orthopedics, it is also evaluating cardiology procedures that can be performed safely in ASCs.
“The opportunity in a wide variety of cardiovascular procedures is there,” Dr. Sutaria said. “[But], I’ve always been clear that I think that that opportunity will proceed more slowly than people anticipate.”
HCA Healthcare
Nashville, Tenn.-based HCA Healthcare, one of the nation’s largest ASC operators, runs its facilities under the Surgery Ventures division. By the end of 2024, it managed 124 ASCs, with an average of 14 outpatient facilities per hospital. Holding a 2.3% market share, HCA Healthcare pursued a growth strategy focused on new facility construction, greenfield developments, and targeted acquisitions.
HCA Healthcare faces challenges expanding its ASC network in states with certificate-of-need laws, CFO Mike Marks said during the health system’s Jan. 24 earnings call. Mr. Marks noted that HCA can expand its outpatient network “much more quickly and aggressively” in states without CON laws. In contrast, regulations in states such as Georgia, Virginia, and North Carolina create barriers that slow or limit the company’s ability to develop new ASCs.
The health system’s ASC strategy is driven by “greenfield developments” — new facility constructions — along with targeted acquisitions, CEO Sam Hazen said in a third-quarter earnings report.
Mr. Hazen said Sept. 5 at both the Morgan Stanley Global Healthcare Conference and the Wells Fargo Healthcare Conference that the health system has an average of 13 outpatient facilities for each hospital. By 2030, he expects that average to grow to between 17 and 20.
Mr. Hazen said at the Morgan Stanley conference that HCA wants “to extend the reach of our network for our patients, make it more convenient for them to start their process of care somewhere in the HCA system.”
He said its approach is to “take as many outpatient facilities as we possibly can and make it closer to the patient.”
Surgery Partners
Brentwood, Tenn.-based Surgery Partners is the third-largest ASC operator in the U.S. and oversees more than 160 centers and 4,600 affiliated physicians. In 2024, Surgery Partners added five new ASCs and two orthopedic ASCs in Chicago through a partnership with Duly Health. It also added over 230 physicians across orthopedics, spine and cardiology.
Surgery Partners performed more than 117,000 orthopedic cases in 2024, 11% more than 2023, reflecting its focus on orthopedics through “targeted recruiting, acquisitions, and de novos,” CEO Eric Evans said in its fourth-quarter earnings call.
Surgery Partners saw a 50% increase in total joint procedures in 2024, reflecting the company’s strategic focus on expanding high-acuity orthopedic services. More than 70% of its surgical facilities are now equipped for complex orthopedic cases, and 41% of its ASCs currently perform total joint replacements. The company also added 14 surgical robots in 2024, allowing its physician partners to perform increasingly complex procedures with greater precision.
Surgery Partners also continued its ASC expansion efforts, opening eight de novo facilities throughout the year. With 12 more centers in the pipeline, many of which are slated to open in 2025, the company remains committed to developing at least 10 new ASCs annually. These projects are backed by well-established physician partners specializing in high-growth areas, including total joint replacements, spine procedures, and other high-acuity services.
Investment in growth remained a priority, with nearly $400 million in capital deployed in 2024, primarily toward facilities specializing in orthopedics and spine surgery. By investing in new equipment, including robotic-assisted surgical platforms, and recruiting specialists in key markets, Surgery Partners is positioning itself to meet rising orthopedic demand.
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