Who better to answer that question than someone who's worked on opposite ends of the outpatient surgery spectrum? Her name is Paula Russo, RN, and her impressive resume shows that she's launched two freestanding surgery centers and is currently the director of Bayfront Same Day Surgery Center, LLC, a physician-hospital joint venture in St. Petersburg, Fla., that did more than 8,000 cases in 2003.

Once you step inside the surgery center, it looks like any other six-OR, three endo-suite facility might. But there's no escaping the fact it's tethered to a hospital, physically (a walkway connects it to the Big House), financially (the hospital has a 51 percent ownership stake) and culturally (who's idea was it to put the surgery center on the second floor, above the cafeteria?).

"This is a different animal than a freestanding center," says Ms. Russo. "It's difficult not to have control over everything. As administrator, you want to have control over your people and your polices. You always have more freedom and control in a freestanding center than an HOPD, and there's a lot of red tape in hospitals. But on the other hand, the hospital can be a big help."

Good point. HOPDs have inherent advantages over ASCs, including leveraging the hospital's clout to secure better managed-care contracts as well as being able to contract with the hospital many of the services - such as human resources, infection control, purchasing, safety, risk and quality improvement - administrators in ASCs are left to juggle themselves.

"Instead of me taking my time to do it, a [hospital] department is obligated to do it," says Ms. Russo. "That would take a lot of my time in a five-day work week."

Though you wouldn't always know it by the content of our pages or the beat of the industry, hospitals are where most of our readers work and where most outpatient surgery is done.

Despite the rapid rise of alternative-site surgery, 43 percent of the 47.5 million surgical procedures expected to be performed next year will be done in HOPDs. Less than one-fifth (17 percent) will be done in ASCs, according to projections.

Those numbers are reflected in our circulation breakdown. More than one-third (9,054) of the more than 26,000 surgical decisionmakers who receive Outpatient Surgery Magazine are hospital-based. About one-fourth (6,262) work in ASCs.

In time, if the lawmakers don't interfere, ASCs may overtake HOPDs in terms of surgical cases and magazine readers. But the market will remain fragmented, with hospitals, physician-hospital joint ventures, physician- and corporate-owned ASCs and offices seeking their pieces of the pie.