Private equity’s consolidation of anesthesiology has been documented in federal courtrooms, academic studies and state attorney general investigations.
Here’s a breakdown of where that consolidation stands market by market, which ASCs are now effectively captive to a single dominant group and which independent practices are still holding out and why.
How it started: The roll-up model
Anesthesia practices became an attractive target for private equity because procedure volume has grown steadily for decades and anesthesia groups were already more aggregated than other specialties. Additionally, because anesthesia is administered more than 100 million times annually and has a high profit margin, it presents what CCI Anesthesia described in a report as an “easy target for corporate investment by way of contracting with physician management companies.”
Around 20% of anesthesia practices had been acquired through private equity physician practice buyouts by 2020, according to a June 2026 white paper from AMGA Consulting. Additionally, about 33% of anesthesiologists had been absorbed through such acquisitions. By 2024, that share had grown to about 33% of practices, according to the white paper.
The major platforms and their footprints
U.S. Anesthesia Partners, based in Dallas and backed by Welsh, Carson, Anderson & Stowe, Berkshire Partners and GIC, employs about 4,500 clinical team members serving communities in Colorado, Florida, Indiana, Kansas, Kentucky, Maryland, Nevada, Ohio, Tennessee, Texas, Washington and Washington D.C.
North American Partners in Anesthesia, based in Melville, N.Y., is the nation’s largest provider of anesthesia services by facility count. The group first expanded outside of New York in 2002 and reached a footprint in 20 states through its 2020 acquisition of American Anesthesiology from Mednax. Through its affiliated entities, NAPA now has a team of more than 6,000 clinicians and staff offering anesthesia and pain management services at more than 500 U.S. facilities, including ASCs
NorthStar Anesthesia partners with hospital administrators to provide outsourced anesthesia care and is currently partnered with over 200 hospitals in over 20 states with more than 2,000 practitioners.
Premier Anesthesia, based in Alpharetta, Ga., and backed by Jackson Healthcare, manages over 700 providers at hospitals and ASCs in 13 states. In early 2025, Premier forged new partnerships with facilities in the Holzer Health System and with Columbus, Ohio-based Taylor Station Surgery Center.
What consolidation produced: The Texas case study
Texas provides the most documented example of what happens when a single PE-backed group achieves dominant market position. After USAP acquired most large anesthesia practices in Houston and Dallas, commercial anesthesia prices increased 18% within six months and nearly 30% within two years, according to a study from the University of Chicago’s Booth School of Business. In a landmark antitrust case, the FTC alleged USAP bought almost every large anesthesia practice in major Texas metros, leaving hospitals and insurers with few contracting alternatives. Even after new anesthesia practices entered Texas markets, their presence had little effect on reversing USAP’s higher prices, according to the study. The FTC said in court filings that USAP’s own market share data showed many acquisitions resulted in shares above 30% and Herfindahl-Hirschman Index increases over 100, meeting the anticompetition law thresholds.
In April, the FTC and USAP reached an agreement in principle to resolve the litigation. The settlement terms remain confidential while USAP implements proposed relief over the next 180 days, and any final agreement requires FTC and court approval.
Separately, the FTC finalized a consent order with Welsh Carson in January 2025, requiring the firm to limit its involvement with USAP and notify the FTC of specified future acquisitions and investments in anesthesia and other hospital-based physician practices.
In February 2024, the Colorado attorney general also resolved alleged anticompetitive business practices by USAP, with the company agreeing to pay $200,000, divest its exclusive contracts at five Colorado hospitals, and release and modify noncompete agreements with providers.
The roll-up mechanics: How ASCs lose leverage
Beyond acquisitions, consolidation was paired with contracting practices that reduced competition, including aligning rates across acquired practices and limiting entry by rival groups. The core concern, according to the AMGA whitepaper, is not any single transaction, but whether cumulative market power can build through many smaller transactions that individually do not receive the same level of antitrust review as a major merger. Most anesthesia acquisitions fall below the Hart-Scott-Rodino reporting threshold, meaning they are completed without mandatory federal pre-merger review.
“Private, multistate large practices are being bought out by private equity groups,” William Joseph Martin, DO, medical director of anesthesiology at Hugh Chatham Health in Elkin, N.C., and employed by NorthStar Anesthesia, told Becker’s in 2024. “Oftentimes they cut costs by cutting providers. The private equity groups have to make a certain profit, and they’re going to make it one way or the other. In general, more and more hospitals can’t afford to subsidize and the groups have to become larger to have leverage. That’s the way it’s evolving.”
The markets beyond Texas
Texas is not an outlier. A National Bureau of Economic Research working paper by researchers at Yale, Northwestern and the University of Chicago identified 18 anesthesia roll-ups outside the litigated Texas cases between 2012 and 2021, each following the same pattern: a financial sponsor acquires a platform practice, then buys competitors in the same metro market. Together, those 18 markets cover about 20% of the U.S. population, meaning one in five Americans lives in a market affected by an anesthesia roll-up, according to the researchers.
The study names Phoenix, Las Vegas, Louisville and Denver among the large metropolitan markets that saw dramatic consolidation, along with smaller markets including Trenton, N.J., and Syracuse, N.Y. In these markets, concentration as measured by the Herfindahl-Hirschman Index often rose by more than 1,000 points, and in some cases more than 2,500, which is far beyond the thresholds federal antitrust guidelines treat as presumptively problematic. Prices followed the Texas pattern of an 18% increase within six months of an add-on acquisition and 25% to 30% within two years, with no measurable improvement in anesthesia quality.
Denver is the most fully documented of these markets. According to the Colorado attorney general’s office, USAP began purchasing Denver-area anesthesia practices in 2015 and by 2021 had bought out all of its major competitors, establishing control of surgical anesthesia at the two largest hospital systems in the metro area and accounting for more than 70% of health plan reimbursements.
The attorney general’s office said USAP charged reimbursement rates 30% to 40% higher than competing Denver-area groups and demanded subsidy increases as high as 1,200%, and hospitals kept contracting with the group anyway, because by the end of 2020 no independent surgical anesthesia group in the market had the size to fully staff a single hospital.
Who’s still holding out — and at what cost
The independent anesthesia practice has not disappeared, but the economics of staying independent are deteriorating. The workforce shortage, rising compensation demands, and payer reimbursement cuts are compressing the margin of independent groups at exactly the moment PE platforms have the scale to absorb those costs more easily.
The class-action dimension
In February 2026, a class-action lawsuit against USAP related to the allegations of monopolization was expanded to include patients who received care in ASC settings, not just hospital-based patients.
A separate 2022 study found that anesthesia prices increased an average of 26% after private equity acquisitions, with results consistent across the markets studied. More than 20% of healthcare bankruptcies in 2023 were by private equity-backed companies, according to a report from the Private Equity Stakeholder Project — a data point that complicates the narrative that PE consolidation produces stable, well-resourced groups.