The HSS main campus. | Photo provided by HSSHospital for Special Surgery (HSS) spent 163 years perfecting orthopedic care in its core markets. It’s now taking that model national.
Dr. Bryan Kelly, the CEO of HSS, still operates on patients. Not every day, but maybe a day and a half a week, squeezed between board meetings, strategic planning sessions and the general demands of running one of the most recognized orthopedic institutions in the world. But he still does surgeries. And establishing this detail matters, because it tells you something about how Kelly thinks about what HSS is and, perhaps more importantly, what it’s trying to become.
“Our commitment is to protect and extend our focus on clinical excellence,” Kelly (who has been with HSS since 1996) told ASC News. “And really to hopefully play a part in elevating the quality of musculoskeletal care across the country.”
That’s a big statement. It’s also, as of October 2025, a big bet.
Last fall, HSS announced it was partnering with global growth investor General Atlantic to acquire Plano, Texas-based Legent Health. In doing so, the partners launched a new, independently operated national platform of ambulatory surgery centers (ASCs) focused on orthopedic and spine care.
“This platform brings together HSS’s clinical knowledge and General Atlantic’s company-building expertise to create community-based platforms that will expand patient access to premier orthopedic and spine care,” Robbert Vorhoff, managing director and global head of health care at General Atlantic, said at the time.
For HSS – an institution whose roots were cemented carefully, organically and almost entirely within the New York metropolitan area – it was a notable pivot.
Yet the timing couldn’t be better.
“This is an opportunity for us to expand HSS quality care to more patients in more locations at greater convenience and greater value,” Kelly said.
Dr. Bryan Kelly, the CEO of HSS. | Photo provided by HSS
The shift nobody could ignore
Before the COVID-19 public health emergency, roughly half of orthopedic procedures were authorized by insurers to be performed in an outpatient setting, according to Kelly. At HSS specifically, an even larger percentage of surgeries were still happening in the inpatient setting.
Then the pandemic hit, and the math changed fast.
“Since COVID, it’s accelerated,” Kelly said. “Now … close to 80% of orthopedics is being authorized for payment as an outpatient surgery.”
It’s a trend happening throughout U.S. health care, as payers, physicians and patients push for more seamless, consumer-centric and, yes, affordable care. Policymakers are driving the shift as well, with the U.S. Centers for Medicare & Medicaid Services (CMS) steadily adding procedures to the ASC Covered-Procedures List, including incredibly complex ones.
“It’s really this accelerated migration that makes now the right time,” Kelly said. “I would also [point to] the organizational readiness at HSS.”
Kelly’s colleague, Dr. Michael Ast, HSS’ chief medical innovation officer and director of ASC strategy, has been watching this shift play out in his roles as well. Ast also serves as the John N. Insall endowed chief of knee service.
Ast told ASC News that he started performing outpatient hip and knee replacements in an ASC in 2014 – well ahead of most of his peers – and has spent the years since helping HSS figure out what to do about it strategically.
“This has been, actually, quite a long journey for me,” he said.
In recent years, payers have increasingly recognized the value of ASC, Ast explained.
“Prior to COVID, … the payers weren’t so aware of [outpatient surgery] and weren’t so on board,” he said. “Now that they’ve seen the success, they’re actually driving a lot of the change. In health care, real dynamic change requires all the stakeholders to be on the same page.”
Why now, why Legent, why General Atlantic
By the time Kelly and his team started seriously evaluating an expansion strategy, HSS had built or planned at least seven ASCs: five in its core tri-state market as well as Florida, with a sixth recently opened and a seventh in Long Island.
That’s not nothing. But it’s also not a national platform.
“The economics of inpatient surgery have become, and will become increasingly so, more and more challenging,” Kelly told ASC News. “Because the cost is outpacing the revenue, and we need to create more cost-efficient and value-based care locations.”
To launch a national strategy, HSS and its new capital partner – General Atlantic – wanted a platform it could build and jump-start their goals. That’s where Legent came in.
Kelly and his team evaluated several acquisition targets before landing on Legent, he recalled.
“We looked at a bunch of – dozens of – different potential initial platforms,” Kelly said.
The Plano-based Legent had built a focused orthopedic and spine ASC network in high-growth markets, such as Texas and Florida, with established governance, outcome measurement infrastructure and, critically, a culture that was already aligned with what HSS cared about most.
“They had a total willingness to work with us to implement standardized clinical care pathways,” Kelly said. “And not only willingness – they strongly wanted that.”
What’s more, HSS knew a lot of the Legent team
“In many of the sites, we knew surgeons in those locations, so we knew the quality was already there,” Kelly said.
General Atlantic, meanwhile, brought a proven health care record and confidence that it would be able to help HSS grow. The firm had recently executed a similar model in oncology, which gave Kelly a template for how General Atlantic thinks about health care partnerships in more long-term and value-driven terms, he said.
As a firm, General Atlantic doesn’t really take a half-hearted approach either. It tends to go big.
Just this month, it reportedly acquired TEAM Services Group from Alpine Investors for a whopping $3 billion, valuing the home-based care company at a 10 times EBITDA multiple, according to Bloomberg. TEAM operates in all 50 states and employs 100,000 caregivers and household staff, offering agency-based home care and a variety of other services.
Scale, of course, can be seductive. And it can be a double-edged sword in health care when it’s prioritized over quality, a pitfall many operators have fallen into in recent years.
Ast, who has spent years thinking about the clinical and strategic dimensions of the outpatient migration, is clear-eyed about where things can go wrong. As more procedures shift into ASCs – not just joint replacements and routine spine cases, but increasingly complex revisions and higher-acuity surgeries – the temptation to chase volume at the expense of rigor is real.
“The biggest risk is the misinterpretation of the value formula,” Ast told ASC News. “People start to think that the only driver of the increasing utilization of outpatient resources is to lower cost. What happens is they keep lowering costs, they keep lowering costs in a race to the bottom, and they affect the quality of care.”
He referenced the Walmart Centers of Excellence model as a cautionary tale – a well-intentioned effort to direct patients toward high-value, low-cost providers that, in some cases, prioritized price over quality with consequences for patients.
“The No. 1 thing we need to make sure is that, at all times, the patient remains the center of this,” Ast continued.
The key to scaling a national ASC platform and shifting procedures into the outpatient setting more broadly, in Ast’s view, is evidence, protocols and this unwavering focus on patient selection.
“It still needs to be a super evidence-based, super protocol-driven, super patient-centric move,” Ast said. “And then if all of that’s done, I’m excited to see … even more stuff be available to more patients at an ASC.”
For HSS, General Atlantic and Legent, there’s also a longer game being played here focused on payer strategy and value-based care.
Data standardization, for instance, is another important opportunity in the Legent partnership. Orthopedic data, Ast noted, is abundant but messy. A national platform with standardized clinical protocols creates the infrastructure to actually make sense of it, which, in turn, has a lot of value to potential payer partners.
“We can start to standardize the data,” Ast said. “We can start to share the data amongst groups outside of the Upper East Side of Manhattan and the surrounding tri-state area, right? And start to try to understand that data in the landscape of larger and more diverse populations.”
Dr. Michael Ast, HSS’ chief medical innovation officer and director of ASC strategy. | Photo provided by HSS
Defining success
HSS has been ranked the No. 1 orthopedic hospital in the country for 16 consecutive years. It has more than 2,000 alumni practicing orthopedic surgery across the U.S. It performs 46,000 surgeries annually and sees more than 500,000 patients per year. By seemingly any reasonable measure, it has already made its mark.
So why shake things up?
In some regards, not moving or innovating is its own kind of risk, particularly in today’s health care landscape. HSS wants to stay ahead of the curve, and it wants to bring its playbook to the rest of the country.
“We have very mature clinical protocols,” Kelly said. “We have a strong outcomes discipline based upon data, and we can really create connectivity between what’s happening on the main campus and any of our regional sites. We know exactly how our quality stacks up in one location vs. another.”
“And our leadership infrastructure is now set up in a way that I think we can scale responsibly, and I think we have the right people in the right place,” he added.
When asked what success looks like for the HSS, General Atlantic and Legent partnership, Kelly focuses on consistency.
“It’s building and growing, but maintaining consistency with our clinical outcomes,” he said. “Making sure that we’re expanding access to high-quality orthopedic and spine care to people in locations where they can’t get it now. Strong physician engagement. Co-ownership. We’re growing this together.”
That last part – co-ownership – is a point of focus, too. The future of the ASC market, Kelly and Ast both believe, belongs to models where surgeons aren’t just employees executing someone else’s strategy. They’re partners with skin in the game who are aligned around outcomes.
“High-quality care starts with high-quality doctors,” Kelly said. “We need to make sure we get the right people who are engaged and driven by the same principles.”
*Editor’s note (April 16, 2026): A previous version of this story incorrectly stated HSS has an ASC in Malvern, Pennsylvania.
