Image by Rita Kazinczi from PixabayAmbulatory surgery center (ASC) growth in 2025 wasn’t evenly distributed across the map.
In line with historic trends, it clustered in a handful of large states and metropolitan markets where competition is intense.
That’s according to recently released data from ASC Data’s Q4 2025 Insights Report. The report affirmed how out of the more than 6,500 Medicare-certified ASCs operating nationwide, nearly all are concentrated in urban areas.
Specifically, about 91% carry an urban designation, according to ASC Data, underscoring how decisively outpatient surgical infrastructure has gravitated toward dense population centers.
In terms of states, California remains the nation’s largest ASC market, with 917 Medicare-certified centers. Florida follows with 531, and Texas with 505. Together, those three states account for nearly one-third of the Medicare-certified ASC universe.
The clustering becomes more apparent at the city level. Las Vegas leads the country with 58 ASCs, followed by Atlanta with 53 and Houston with 51. Phoenix, San Antonio and Beverly Hills also rank among the top markets.
The numbers point to an industry that is expanding inward rather than outward – with market density more important than the volume of “pins on the map.” Instead of pushing into new geographies, growth appears to be concentrating in established, high-volume metros where physician supply, payer mix and demographics support scale. Health system-ASC investment has also likely influenced this trend.
Reflecting this idea, Atlas Healthcare Partners has focused on strategically aligning its ASCs with its health system partners based on their goals for geographic coverage and capacity in their markets, President and CEO Aric Burke told ASC News.
It also takes into account service line coverage and physician alignment, Burke explained.
“ASCs require a critical mass of physicians and volume to cover fixed and variable costs and generate a profit and cashflows, so we need to ensure the market can support each ASC,” he said. “We also find that density creates greater scale and operational efficiencies allowing us to invest in local employees, float pools and greater collaboration and integration between the ASCs and the health system.”
Operating room counts reinforce the pattern.
California has 2,139 ASC operating rooms, Texas 1,615 and Florida 1,572 – the highest totals in the country. Larger facilities, including those with five or more operating rooms, are more likely to appear in these dense markets, often backed by health systems or private equity sponsors seeking regional dominance.
Overall, there are currently 18,781 operating rooms across the 6,500-plus Medicare certified ASCs in the U.S.
ASC Data additionally provided insights on the ASC market based on where ASCs are pulling out. In Q4, 49 ASCs were added to the Medicare-certified dataset while 28 were removed. Some of the removals were concentrated in states already dense with facilities, suggesting consolidation, downsizing or strategic repositioning.
Some examples of removals, according to ASC Data, include South Central Endoscopy in Hot Springs, Arkansas; Kootenai Outpatient Surgery Center in Coeur D’Alene, Idaho; and Portsmouth Regional Ambulatory Surgery Center in Portsmouth, New Hampshire.
Steve Hockert, chief development officer for Solara Surgical Partners, also emphasized how the next phase of ASC growth will be defined less by map coverage and more by strategic executions within markets that can support scale.
“Population density creates potential for operational leverage,” Hockert told ASC News. “Larger markets can support higher-acuity migration, multi-OR facilities and long-term payer alignment. That’s where disciplined growth might outperform opportunistic expansion over the long term.”
“At the same time, the rural access gap remains a structural issue,” he added. “The challenge isn’t simply building more centers – it’s aligning physician leadership, reimbursement realities. and sustainable volume.”
Urban concentration leaves rural gaps
Indeed, the flip side of metro saturation is rural scarcity.
With roughly 9% of Medicare-certified ASCs located outside urban areas, large swaths of the country remain dependent on hospital outpatient departments or long travel times for surgical care.
While some rural states show moderate ASC penetration, the overall distribution remains heavily skewed.
That’s not to say there aren’t opportunities, however.
“Large hospital systems in urban areas could increase market share by partnering with surgeons to develop rural regional ASCs,” Lisa Austin, a senior adviser with Avanza Strategies, told ASC News. “This would allow patients to have closer access to surgical care. Allowing the surgeons to have ownership in the partnership would be attractive.”
That imbalance has implications beyond competition. Health care policymakers have increasingly scrutinized access disparities. And with more procedures migrating out of hospitals, there’s generally a growing focus on outpatient resources.
In markets where hospitals have closed or reduced services, the absence of ASC infrastructure can widen care gaps, particularly for lower-acuity procedures that might otherwise be candidates for outpatient settings.
Of course, the economic realities that drive metro clustering – higher population density, stronger commercial payer mix and greater physician supply – also make rural expansion more challenging. Smaller populations often cannot support standalone facilities, and recruiting specialized staff can be difficult.
“Developing ASCs in rural areas is challenging due to the lack of physicians and volume as well as the impact on the hospitals,” Burke said. “Smaller hospitals rely heavily on surgical volume and revenue to survive, and ASC competition could cause both to struggle financially and go out of business, which has serious consequences for the community, physicians and employees. We see a lot of patients travel into higher population areas for a surgery or procedure and have aligned with physicians from more rural areas to utilize our ASCs as needed.”
When outpatient surgery isn’t naturally available in a market, there are other models to consider as well.
“I know some areas where surgeons fly to a rural surgery center one to two days per week, and this model works well,” Austin said. “It might be orthopedic cases one day, followed by pain management, GI, or ophthalmology. Sometimes their staff members from the urban ASC travel with them, if staff aren’t available in the rural location.”
“Another concept I have seen work is for ASCs to partner with the rural hospitals and have limited days for ASC cases,” she continued. “If hospitals can assist in negotiating payer reimbursement for the ASCs at a level that makes sense, patients can stay closer to home to receive high-quality care at an ASC specializing in the surgeries they require, with a lower copay and deductible expense.”
But for now, the data suggest that ASC growth will likely continue to favor scale and density over geographic diversification.
“The rural market has always been an issue for the reasons you mention regarding surgeon recruitment, staff recruitment and reimbursement,” Austin said. “But with some creative strategies, there are ways to expand successfully in rural markets.”
