Like many surgeons, I scheduled my ENT practice's first few years of procedures in hospital ORs or at area surgery centers. By the late 1990s, as we expanded into a multispecialty practice, we added a freestanding operating theater for self-pay cosmetic surgery and limited insurance cases. Soon after, we began asking ourselves, "Where do we go from here as a group practice?" One answer was to build our own ambulatory surgery center. But we operated in Connecticut, a state with rigid certificate of need laws and hospitals defending their market share. Our solution? We proposed a physician-hospital joint venture.