We agree with Dr. Temianka that utilization management that is conducted thoughtfully and grounded in evidence-based medicine can often both control costs (by decreasing utilization) and increase appropriateness of care. In fact, RAND has been at the forefront in documenting the inappropriate overutilization of many procedures [1, 2]. In describing the variability of utilization management methods currently used by capitated physician groups, we sought to help physicians focus on methods that are most valid and would help physicians produce the most value for the cost.

We also agree that current guidelines are numerous and vary in quality. We submit, however, that once a physician group has accepted the responsibility to provide medical care to an enrolled population, it must also minimize inappropriate variability by evaluating, adapting, or developing guidelines for conditions and treatments that the group frequently encounters. This task, although formidable, is eased somewhat by following the criteria for valid clinical practice guidelines set forth by the Institute of Medicine [3]. Groups that follow these criteria could set aside most currently available guidelines. As physicians, we must take the lead in setting our own standards for practice, unless we want to practice by standards dictated to us by others. If we are to be proactive and retain autonomy, it is up to us to implement valid management and monitoring tools and up to the research community to make such tools available. In doing so, we will decrease variation and improve quality of care for our patients. Because we are physicians, we can also recognize that patients are individuals and that guidelines should be implemented in a manner that respects individual differences.