Medicare inpatient joint discharges fell from 542,513 in 2017 to 127,759 in 2024 after CMS removed knees (2018) and hips (2020) from the inpatient-only list. The remaining phaseout runs through 2028, and hundreds more procedures join the ASC covered list. The average Medicare payment: $16,328 inpatient, $10,784 hospital outpatient, $6,909 in an ASC.
Each of the 384 scored markets gets a 0–100 score for how much room joint replacement still has to move outpatient. Six weighted components: the share still done inpatient (30%), total joint volume (25%), certificate-of-need openness (20%), how few ortho surgery centers already exist (10%), TEAM episode pressure (10%), and ACO coverage (5%). High score = demand exists, it is still inpatient, and nothing stops a surgery center from taking it. You can change the weights yourself in the rankings.
Gold dots are Medicare surgery centers, sized by their visible joint replacement volume. Coral circles are hospitals, sized by inpatient hip and knee discharges, with a dark ring on TEAM participants now accountable for 30-day episode cost. Diamonds are ACO headquarters. County shading carries whichever lens you pick: runway, inpatient share, CON openness, or ACO coverage.
Certificate-of-need law decides whether anyone can build. Twelve states never had CON, a dozen more exempt ASCs, and the door keeps opening: South Carolina repealed in 2023, North Carolina's urban ASC exemption took effect November 2025, Maine exempted most ASCs in March 2026, and Tennessee's CON for surgery centers ends December 2027. The CON lens shows each state scored 0 to 1, with the statute notes in the methodology.
The LEAD model's CMS-Administered Risk Arrangements let accountable care organizations hold specialists to episode risk starting 2027. Its participant list isn't published yet, so the map shows the likeliest applicants: REACH ACOs and the 476 Shared Savings ACOs, each with its IRF and SNF admission rates. An ACO with heavy post-acute spend in an open-CON market is the natural counterparty for an outpatient joint program.
Markets ranked by the Outpatient Runway Score, and hospitals ranked by how much they need an outpatient total joints strategy. Move the weights and the map re-scores with you.
IRF and SNF admissions are per 1,000 assigned beneficiaries (2024 results); higher rates mark the ACOs whose post-acute spend an episode arrangement could buy down. LEAD participants are not yet published; REACH ACOs are the nearest surrogate.
Five national operators hold about a fifth of Medicare-certified ASCs, and the ranks changed in 2026: Ascension bought AmSurg, Optum began selling centers, Surgery Partners chose to de-lever, and USPI kept compounding. Every affiliated center we could tie to a parent is drawn on the map and counted here.
| Platform | Scale | Sponsor / partners |
|---|
Affiliation method: legal-entity names from Tenet, Surgery Partners and HCA 10-K Exhibit 21 (FY2025), Surgical Care Affiliates (FY2016) and AmSurg (FY2015) Exhibit 21 for legacy rosters, and operator location directories or career sites retrieved September 1, 2026, matched to CMS Provider of Services names with state and city checks. "Confirmed" means an exact or city-verified name match; "probable" means a strong name match without a city check; "legacy" means the only evidence is a pre-2017 filing. Equity-method USPI centers and SCA centers without open job postings are under-counted, so operator totals here are floors.
Medicare-certified surgery centers grew about 2% a year for five years. Medicare spending on them grew 16% in 2024, because the cases moving in are joints, spine and cardiac work. The count of centers understates the growth in what they do, and the CY2026 and CY2027 rules add roughly 1,200 procedures to the list.
| Year | Inpatient-only list | ASC covered list |
|---|
One market, read the way the Pro modules read all 384. Nashville has the largest operators' headquarters, sixteen hospitals under mandatory TEAM episodes, a certificate-of-need law that expires in December 2027, and a joint book that has already left the ward. Every number below is computed from the same files as the map; superscripts go to the source.
| Hospital | Inpatient TJA | HOPD MSK | Inpatient share | TEAM |
|---|
Nashville is also a headquarters market: HCA Healthcare7 and AmSurg10 are based in Nashville, Surgery Partners in Brentwood8, and USPI's largest local partner is Ascension Saint Thomas through the Baptist Surgery Center joint venture6. Corporate development teams here drive past their own targets on the way to work.
Rates. Commercial and Medicare Advantage ASC rates for 27447/27130 from the Transparency in Coverage files for BlueCross BlueShield of Tennessee, UnitedHealthcare and Cigna, against the HOPD rates in TriStar's and Saint Thomas's price-transparency files. Net revenue per case decides the pro forma; Medicare tells you only the floor.12
All-payer volume. Tennessee's Hospital Discharge Data System and HCUP SASD for the true outpatient joint count; the map sees Medicare FFS, and 52% of Nashville beneficiaries are in Medicare Advantage.1
Pipeline. Tennessee Health Facilities Commission CON applications and letters of intent filed in the 2026 and 2027 cycles: the de novos that will certify after this map's data.9
Labor. BLS OEWS CRNA and RN wages for the Nashville MSA and the anesthesia stipend market; 44% of ASCs paid a stipend in 2025.13
Five forces, scored 0–100 against the 384 scored markets from public files: rivalry among existing centers, the threat of new entry, payer power, hospital incumbency, and enterprise consolidation. High scores mean the force pushes harder against a new entrant.
The five cards below explain each force in plain language for the selected market.
Force profiles, enterprise presence, five-year supply history, comparable markets and persona-specific reads for all 384 scored markets.
The Runway Score asks where joint replacement still has room to leave the hospital. The Viability Index asks a narrower question: given demand, headroom, regulation, existing supply, enterprise saturation and payer mix, where would a new surgery center be most likely to fill its rooms. Presets reweight it for each persona; every slider is yours to move.
Persona-weighted site-selection rankings for every scored market, per-market scorecards, and a working single-center pro forma seeded with 2026 benchmarks.
Everything the map relies on, plus the numbers an operator, a surgeon group or a strategy office reaches for during a site decision. Links go to primary sources wherever one exists.
| Source | What it adds | Status here |
|---|---|---|
| CMS Provider of Services (POS), quarterly | Every certified ASC and hospital, certification dates, control type, county and CBSA | Integrated, eight vintages |
| SEC 10-K Exhibit 21 subsidiary lists | Legal-entity rosters for Tenet/USPI, Surgery Partners, HCA; legacy SCA and AmSurg | Integrated |
| Operator directories and career sites | Current DBA names and cities for SCA, AmSurg, USPI, Surgery Partners, Atlas, Compass, Constitution, Regent, Solara | Integrated, partial for USPI and SCA |
| Medicare Physician & Other Practitioners (POS 24) | Surgeon-level ASC volume by procedure | Integrated for TJA; other specialties next |
| Transparency in Coverage payer files | Negotiated commercial rates by ASC and HOPD, the input for a real rate check | Analyst brief |
| Hospital Price Transparency MRFs | HOPD negotiated rates for the same CPTs | Analyst brief |
| HCUP SASD / NASS | All-payer ambulatory surgery encounters in participating states | Analyst brief |
| State CON dockets | Pending ASC applications: the de novo pipeline before it is certified | Roadmap |
| BLS OEWS (CRNA, RN wages by MSA) | Labor cost layer for the pro forma | Roadmap |
| KFF Medicare Advantage penetration by county | Payer mix modeling | Integrated at county level |
| VMG Intellimarker / HealthCare Appraisers | Current net revenue per case, margins and multiples by specialty | Licensed data; benchmarks above are public editions |
The map, the Runway Score, the operator landscape, the trends and the Nashville study are free. The Pro modules are a Founding member resource. Organizations license seats; analyst briefs run your own claims through the same machinery.
Founding members: your Pro key is in the founding welcome email and on the members page. Operator licenses receive their keys by email.
Keys are checked in your browser and remembered on this device. Signed-in Clubhouse admins and Founding members are recognized automatically. Member sign-in
Every number on this page comes from a public federal file. The score is a weighted blend of percentile ranks, so a market's position depends on where it sits relative to the other scored markets, not on any absolute threshold.
The map answers one question: where does outpatient joint replacement have the most room to grow. Room to grow is a product of demand that already exists (volume), the share of that demand still delivered in the most expensive setting (inpatient share), the regulatory permission to build capacity (certificate of need), the absence of capacity already built (ortho ASC density), and the presence of institutions under new financial pressure to move cases (TEAM hospitals and risk-bearing ACOs).
The inpatient-only list phaseout scheduled for 2027 and 2028, together with the ASC covered procedure list expansion, means site of service is becoming a clinical and financial decision rather than a regulatory one. A market with high inpatient share, open CON, and few ortho surgery centers is a market where that decision has not yet been made.
Hospitals are scored separately on the need for an outpatient total joints strategy: 45% inpatient hip and knee volume (log percentile), 30% the hospital's own inpatient share of its arthroplasty-level cases (DRG 469/470 discharges against APC 5115 outpatient claims at the same facility), 15% the CON openness of its market, and 10% TEAM participation. A high score means a large inpatient book in a market where competitors can open surgery centers freely, and where the hospital itself is now accountable for episode cost.
All volumes are Medicare fee-for-service only, from the 2024 public use files, and counts under eleven are suppressed at the source. Medicare Advantage, commercial, and Medicaid volume are invisible here, which understates markets with high MA penetration. Inpatient share compares hospital DRG discharges against orthopedic surgeon professional claims in the same market, so cross-market referral flows add noise, and hospital-level outpatient volume uses APC 5115 as a proxy that includes other level-5 musculoskeletal procedures. ASC facility volume is visible only where a center billed at least eleven Medicare joint replacements. CON status is a curated reading of state law as of August 2026; verify with counsel before any capital decision.
ACO layers use 2024 assigned-beneficiary counts by county for the Shared Savings Program and aligned-beneficiary counts for ACO REACH, plus the 2026 participant lists. The LEAD model's CMS-Administered Risk Arrangements, which will let ACOs contract episode risk with specialists from 2027, have no published participant list yet; REACH ACOs are the closest surrogate for the organizations most likely to be there.
Elective inpatient discharges (MS-DRG 469 + 470) at hospitals in the market, divided by joint replacement professional claims (CPT 27447 + 27130, facility setting) billed by orthopedic surgeons in the market. Higher share, more runway.
Log of surgeon joint replacement claims in the market. Demand has to exist before it can move.
1.0 where no CON applies to ASCs; 0.8 with a broad exemption in force; 0.6 where repeal is scheduled; 0.3 where CON stands with narrow reform; 0 for full CON. Beneficiary-weighted across states in multi-state markets.
Inverse percentile of orthopedic-certified ASCs per 100,000 fee-for-service beneficiaries. Fewer existing ortho centers, more room.
Count of hospitals in the market that are mandatory or voluntary TEAM participants, accountable for 30-day episode cost on lower extremity joint replacement since January 2026.
Share of fee-for-service beneficiaries assigned to an MSSP or REACH ACO. Risk-bearing primary care is the counterparty for specialist episode arrangements.
Legal-entity rosters from Tenet, Surgery Partners and HCA 10-K Exhibit 21 (FY2025), legacy Surgical Care Affiliates (FY2016) and AmSurg (FY2015) exhibits, and operator directories and career sites retrieved September 2026, matched to CMS Provider of Services names by distinctive tokens with state and city verification. Health-system branding is inferred from facility names. Coverage is a floor.
Each ASC's CMS certification number is tracked across eight Provider of Services vintages (December 2019 through Q2 2026). A center opens the first year it appears active and closes the year after it last appears. Counties roll up to 2023 CBSAs.
Five 0–100 scores from percentile ranks across scored markets: rivalry (OR density and supply momentum), threat of entry (CON openness), payer power (Medicare Advantage and ACO coverage), hospital incumbency (inpatient share and TEAM presence) and enterprise consolidation (enterprise share and an operator HHI in which each independent center counts as its own firm).
A second weighted blend of percentile ranks built for site selection: demand, headroom, CON openness, low existing supply, fragmentation, supply momentum, fee-for-service visibility, TEAM pressure and ACO coverage. Presets reweight it for surgeon groups, operators and health systems; supply and fragmentation are inverted under the health-system preset.
| State | Status for ASCs | Score | Note |
|---|
The public files stop at Medicare fee-for-service and suppress small counts. An analyst brief adds surgeon-level volume across payers, your hospitals' own discharge destination mix, and a site-of-service pro forma for the episodes TEAM now holds you accountable for.