ASC and AIC 2026 Watch

The ambulatory thesis is no longer contrarian. It is consensus. And consensus markets reward operators who underwrite specialty risk with precision, not buyers chasing the obvious top-line growth story. This is a quarterly view on where real value is forming in ambulatory surgery centers and ambulatory infusion centers, and where the easy trade is already over.

The headline numbers

The US ambulatory surgery center market sat at $43.75 billion in 2025 and is projected to reach $80.6 billion by 2035, compounding at 6.3%. Volumes are expected to grow 9% between 2023 and 2028, outpacing hospital outpatient department growth at 7%. The Southeast accounted for the largest regional share at 11.7% in 2025.

The ambulatory infusion center category is moving faster. Global AIC revenue is forecast at $57.93 billion in 2026, growing 11% annually through 2033. McKinsey estimates the broader US infusion services market at $120 billion, growing 8% to 10%. North America holds 40.6% of global AIC market share. Private equity has been deploying heavily since 2020, and the AleraCare and Pure Infusion Suites combination created a 75-site, 14-state platform that signals where the consolidation arc is heading.

Two markets, both expanding, both attracting capital, both reaching the inflection point where the easy growth story gets harder to underwrite without specialty competence.

What changed this quarter

Three shifts worth tracking.

CMS expanded the ASC Covered-Procedures List for 2026 and continued phasing out the Inpatient-Only List. Cardiac ablation codes were approved for ASC reimbursement, reshaping development pipelines for cardiology-focused centers. Fewer than 5% of eligible patients currently receive ablation, so the demand-side runway is significant. The proposed 2.4% market basket update for 2026, on top of the 3.1% update in 2024, continues the site-neutral trajectory that has underpinned ASC investment thesis for a decade.

Health systems shifted from defensive to offensive. Ascension's $3.9 billion acquisition of AmSurg added 250 ASCs across 34 states. HCA continues divesting hospital assets in favor of outpatient growth through USPI. Incumbent systems now treat ambulatory networks as enterprise infrastructure, not ancillary business. This compresses the window for independent platform creation in mature urban markets and widens it in underserved Southeast and Midwest geographies.

Infusion M&A is consolidating around specialty-drug economics. Cencora's roughly $5 billion acquisition of a physician-led oncology network and the AleraCare/Pure Infusion Suites combination both reflect the same underwriting logic: providers focused on high-margin specialty biologics command premium multiples. Immunoglobulins, monoclonal antibodies, oncology infusions. Lower-acuity hydration and antibiotic-focused operators do not trade at the same level. Site-of-care arbitrage continues to favor AIC and home over hospital-based delivery, and payer steering reinforces it.

Where the real value sits

The ambulatory shift is broad. The underwriting logic that compounds is narrow.

The ambulatory shift is broad. The underwriting logic that compounds is narrow.

On the ASC side, three segments are worth watching: orthopedic and spine, cath labs, and GI. Orthopedics held 27% to 31% of ASC revenue across 2023 and 2024 depending on the data source. Bain projects ASCs will perform around 30% of all spine surgeries by the mid-2020s, up from 10% in 2018. Cardiology is the fastest-growing specialty in the category, and CMS approval of cardiac ablation accelerates a thesis that was already moving. GI is the most mature segment by procedure volume, but multi-site operators with payer leverage and physician alignment still trade at attractive multiples.

On the AIC side, the value drivers are neurology, oncology, GI infusion, and IVIG/immunoglobulin therapy. Economics are driven by drug mix, not facility footprint. AICs delivering high-margin specialty biologics command meaningfully higher multiples than mixed-acuity operators. More than 60% of drugs in the FDA pipeline are infusion-delivered, which means the demand curve is built into the next decade independent of reimbursement reform.

What is not worth chasing in the current cycle: ophthalmology and dermatology platforms, where consolidation is largely complete and multiples reflect that. Plastic surgery, where regulatory and reimbursement dynamics don't favor the platform thesis. Hospital-affiliated ASCs and AICs, where governance complexity and payer dynamics dilute the standalone underwriting case.

What to monitor next quarter

Three watch items into Q2 2026.

First, the CY 2026 OPPS final rule and any further expansion of the ASC Covered-Procedures List. Each new code re-prices existing platforms and re-opens development pipelines. Cardiac ablation is the precedent. Spine and complex orthopedic procedures are the likely follow-on.

Second, Medicare Advantage denial trends in ambulatory settings, which spiked 4.8% year over year in 2024. Site-of-service denials and prior authorization friction directly affect ASC and AIC throughput. Operators who solve for this through payer strategy and contracted RCM partnerships will hold margin while the rest compress.

Third, valuation multiple compression in mid-market AIC platforms. Premium multiples for scaled, specialty-drug-focused AIC operators have held. Mid-market operators with mixed acuity and concentrated payer exposure have started to soften. This is the seam where a disciplined platform-builder can acquire selectively rather than competing for trophy assets at peak prices.

The point of view

This is a 10-year macro story. The trade in 2026 is no longer about whether the shift happens. It is about which sub-specialty, which geography, which physician alignment model, and which payer mix actually compounds at the margin. The operators who win the next cycle will be the ones who can answer those four questions in the same sentence as the LOI.

That is the lens worth building toward.

Independent sector commentary by Dr. Jesus Recio, written from a clinician-operator perspective. Quarterly notes reflect personal sector analysis and are not investment advice.