Report urges tighter oversight as private equity dominates outpatient surgery market.
A new report finds that private equity investment in outpatient surgery centers has grown rapidly and now dominates much of the U.S. market for same-day surgical care. The study, published by the Private Equity Stakeholder Project (PESP), calls for greater oversight and transparency as investors reshape how ambulatory surgery centers—known as ASCs—are owned and operated. ASCs now handle more than 60% of outpatient procedures nationwide, forming an industry worth roughly $30 billion. Over the past decade, private equity firms have made steady inroads into this space through targeted acquisitions, partnerships with hospitals, and platform-style rollups that merge smaller centers under larger management groups. According to the report’s author, policy researcher Michael Fenne, these investors are now influencing not only who owns these facilities, but also how they are financed, staffed, and regulated.
The report draws attention to several large transactions that illustrate the scale and complexity of this investment wave. One of the most notable was private equity giant KKR’s $9.9 billion leveraged buyout of Envision Healthcare in 2018, which included AmSurg, then the nation’s largest operator of surgery centers. The deal relied on more than $7 billion in debt. When Envision filed for bankruptcy in 2023, nonprofit health system Ascension stepped in two years later to purchase AmSurg for $3.9 billion, gaining control of more than 250 centers. Analysts say that transaction shows how large health systems are absorbing the same networks that private equity firms built through a series of smaller, lightly regulated rollups.
Many of those earlier consolidations occurred through deals small enough to avoid federal reporting thresholds. By the time regulators were able to review a major acquisition, the market had already been reshaped. This pattern reduces competition and strengthens the position of health systems or investors that control large networks of centers.
The report also described how private equity firms increasingly form joint ventures with nonprofit health systems to expand their reach. TowerBrook Capital Partners and Ascension Capital invested in Regent Surgical Health in 2021, supporting a model that partners with nonprofits while maintaining investor control. These arrangements allow private equity firms to benefit from the reputation and reach of established hospital systems while sidestepping some of the antitrust scrutiny that larger corporate mergers might attract.
Major insurers have also entered the field. UnitedHealth Group, through its Optum subsidiary, has become one of the most aggressive acquirers of surgery centers, starting with its $2.3 billion purchase of Surgical Care Affiliates in 2017. More recently, Bain Capital, which already owned 39% of Surgery Partners, attempted to buy the rest of the company in a deal valued at about $3.2 billion. When the offer was made public, the company’s stock surged 20%, showing strong investor interest. However, the bid was ultimately rejected by an independent committee that believed the company would perform better as a standalone public business.
According to the PESP report, these examples highlight the need for stronger tools to monitor how ownership structures, debt loads, and pricing strategies affect patients and physicians. Heavy borrowing to finance acquisitions can leave providers financially fragile and more focused on cost-cutting than care quality. Researchers say further study is needed to see how these financial models influence access to surgery, patient outcomes, and long-term healthcare costs.
Transparency remains a concern. In some joint ventures, patients may not realize that their care is being delivered in a facility partly owned or managed by a private equity firm. That lack of visibility makes it difficult to understand how profit motives might shape care decisions, staffing levels, or pricing in outpatient settings.
With private equity now embedded in nearly every corner of the healthcare system—from primary care and emergency medicine to hospice and surgery—experts warn that financial structures built on quick returns can conflict with the long-term needs of patients. As the outpatient surgery industry continues to grow, the report calls for regulators to tighten oversight, track ownership changes more closely, and ensure that profit does not come before patient care.
Sources:
Private Equity Tightens Its Grip on Outpatient Surgery
Private equity and healthcare firm behavior: Evidence from ambulatory surgery centers
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