The way American medicine is practiced is changing rapidly. By the beginning of the next century, most Americans may be enrolled in for-profit managed care plans in which physicians are responsible for both a budget and a population of patients. As health care is revolutionized, the overriding issue is whether the mission of health care organizations will be simply to contain costs, or whether it will be to increase the value (i.e., the quality) that we get for the money we are willing to spend on health care. The purpose of this article is to illustrate for carotid endarterectomy how quality can remain on the health care reform agenda. Vascular surgeons must assume a leadership role, and they must be willing to alter their practice patterns. More specifically, they should: (1) support and facilitate the development of clinically-detailed multispecialty criteria that describe under what circumstances carotid endarterectomy is both appropriate and necessary; (2) support the development of a system for publicly reporting outcome data by physician and hospital; (3) support regionalization of carotid endarterectomy; (4) conduct a prospective assessment of appropriateness before the procedure is performed; (5) consider changing the system by which carotid angiographies are read to increase their reliability; and (6) help develop a system to ensure that people who need carotid endarterectomy are offered the procedure.