A Valuator’s View of the ASC Industry in 2026

Ambulatory Surgery Centers (ASCs) allow patients a vital outpatient care option offering same-day surgery at lower costs in a specialized setting. Over the last decade, the sector has steadily expanded as payers, providers, and patients look for alternatives to hospital outpatient departments (“HOPDs”). In the U.S., more than 6,000 Medicare-approved ASCs perform millions of procedures each year. This growth is driven by advances in minimally invasive procedures and anesthesia techniques, as well as reimbursement policies that favor outpatient surgeries. As healthcare focuses more on cost efficiency, ASCs are increasingly seen as a strategic opportunity.

ASCs' strengths are clear to healthcare operators. They regularly deliver high-quality clinical outcomes, and studies show that procedures in ASCs take less time and demonstrate cost savings. Efficiency is another key benefit: with lower overhead costs and a specialized procedural mix, ASCs typically operate at much lower costs compared to traditional HOPDs. Further, the Medicare Payment Advisory Commission (“MedPAC”) has concluded that Medicare payments for similar services are significantly less at ASCs[1]. ASCs also deliver a better patient experience, scoring higher on convenience, shorter wait times, easier scheduling, and a more welcoming environment, as they are less intimidating and more personal than HOPDs.

However, there are constraints on ASC growth. Centers may have limited capacity, especially in single-specialty centers with limited operating rooms. Staffing shortages, notably in nursing and anesthesia, continue to challenge the industry amid competition from hospitals. Expansion and strategic planning can be complicated and costly. However, ASCs are well-positioned for value-based care and bundled payment programs that reward efficiency and demonstrate high-quality clinical outcomes. Other growth opportunities for ASCs exist in high-acuity specialties such as orthopedics, spine, and cardiology. Technological innovation, including AI tools for scheduling, revenue management, and clinical decision support, may further enhance efficiency.

ASCs are also at risk of changes in Medicare reimbursement policies. Site neutrality policies in Medicare payment, a focus of the current administration, would reduce differences in reimbursement between lower-cost settings like ASCs and HOPDs. This policy could be a challenge to ASCs – although there is hope that ASCs could benefit from equalized rates. Specifically, a challenge would arise if Medicare equalizes payments downward to match the lower Physician Fee Schedule, thereby compressing margins. Conversely, a benefit could occur if the policy lowers HOPD rates and drives more surgical cases into the ASC setting, or if legislation bridges the gap by bringing facility fees closer to HOPD levels. ASCs also require specific management and expertise. Payer contracting, surgical supply chain management, non-clinical staff oversight, and regulatory compliance can be the difference between a profitable enterprise and one that sustains ongoing losses.

Despite these challenges, long-term growth prospects remain promising, driven by demographic trends and the continued shift of procedures to outpatient settings. Physicians see ASC investment as an opportunity to control care delivery, participate in facility economics, and achieve greater alignment with value-based payment models. For many physician organizations, owning ASCs offers both a growth opportunity and a way to enhance financial sustainability amid evolving healthcare demands.  Specifically, equity ownership allows physicians to capture facility-level economics to offset stagnant professional reimbursements, while simultaneously building a high-margin asset.

WHAT MOVES THE MULTIPLE FOR ASCs?

According to DealStats transaction data, ASC EBITDA multiples range from 2.7x to 12.0x, with a median of 10.1x. These valuation ranges reflect differences in size, physician alignment, specialty mix, and perceived risk across facilities.

This table illustrates the link between EBITDA multiples and Size (EBITDA) in the DealStats transaction data.[2]

Higher EBITDA multiples for larger ASCs indicate that the market places greater value on ASCs with a larger medical staff (i.e., more surgeons), specialty and procedure diversification, and economies of scale. We can draw from the data analysis that larger ASCs are deemed less risky than smaller ASCs. Many of the data points in the DealStats data are larger centers, with an average annual revenue of $851 million. In our valuations of smaller ASCs that have lower EBITDAs, we typically expect a 6x-7x multiple, representing a 14% to 17% cap rate.

Mathematical Formula: The capitalization rate (a form of risk/return metric) is the direct inverse of a valuation multiple. For instance, a 10% cap rate equals a 10x multiple, while a 20% cap rate equals a 5x multiple. High-risk businesses (e.g., startups, volatile markets) require a higher rate of return, leading investors to pay a lower multiple of earnings or revenue. If investors perceive higher risk in a business, they reduce the multiple, decreasing the overall valuation. Larger ASCs generally have lower risk profiles, which, all else equal, allows them to command higher, more stable valuation multiples.

This table illustrates the valuation multiple and cap rate relationship:

Other factors that move ASC value multiples:

Physician Depth and Concentration

As previously mentioned, the number of physicians affiliated with an ASC significantly impacts its risk profile. Centers supported by a larger and more diverse group of physicians generally exhibit lower concentration risk and greater revenue stability. Conversely, reliance on a small group of physicians increases exposure to risks such as turnover, retirement, or case migration.

Specialty Mix and Reimbursement Profile

The range of specialties offered within an ASC will influence both revenue stability and reimbursement risk. Multi-specialty centers generally benefit from a diverse case mix and reduced exposure to fluctuations in any single specialty service line. Single-specialty centers may face greater volatility, especially if reimbursement rates or utilization patterns change. Moreover, specialties with typically favorable reimbursement structures can produce stronger, more consistent margins.

Scale and Cost Structure

While larger ASCs may benefit from operational efficiencies, increased scale can also lead to higher fixed costs and greater administrative complexity. If volume declines or the case mix shifts unfavorably, larger cost structures could worsen margin compression, increasing operational risk.

Barriers to Entry and Competitive Positioning

Regulatory barriers, such as Certificate of Need (CON) requirements in some states, can restrict new competitors and lower market risk. Although, notably, over the last ten years, there has been a consistent, nationwide trend of states scaling back, reforming, or completely eliminating CON laws. The lack of CON laws or other barriers to entry for ASCs into a market increases risk. Strong referral networks, exclusive physician relationships, and strategic geographic positioning further boost competitive resilience and decrease long-term market risk.

Less Vulnerability to Reimbursement Risk

Changes in Medicare reimbursement policies, including the possible adoption of site-neutral payment structures, could significantly affect ASC economics. Removing site differences between hospital outpatient departments and ASCs may alter competitive dynamics and lower margins for certain procedures.

Technological and Clinical Innovation Risk

Advances in medical technology, including minimally invasive or non-surgical treatment options, may shift procedure volumes away from traditional surgical settings. However, ASCs are often well-positioned to quickly adopt new technologies, potentially offsetting disruption through cost savings and operational flexibility.

Our 2026 Outlook

Overall, the outlook for ASC values in 2026 continues to be positive. The difference in value multiples will reflect how an ASC fares from a risk profile perspective, with large lower risk centers commanding closer to 8-10x multiples and smaller centers closer to 6- 7x multiples.

[1] Medicare Payment Advisory Commission. Report to Congress: Medicare Payment Policy, Chapter 10: Ambulatory Surgical Center Services. Washington, DC: MedPAC, March 2025

[2] DealStats (Business Valuation Resources)