Although health reform may occur at a macro systems level, in the final analysis its impact is felt in a myriad of interactions among individual patients and providers. Medical costs are the summation of millions of individual decisions-to perform or not perform tests, to prescribe or not prescribe drugs, to operate, to admit to hospital, or to watch and wait. Who should make these decisions accordingly becomes a potent policy issue. Should it be the provider, who has the expertise, but whose income is also affected? Should it be the patient or ‘consumer’? Or should such judgements be left to the payer (whether government, or thirdparty insurer)? Perhaps they should be made by ‘the community’, possibly as represented by institutional or regional boards?