In the October 26, 2009 issue of Time magazine, Jeffry Kluger reviews different options for payment structures for physicians. He cites several clinics that have emphasized outcomes over the traditional fee for service model of paying physicians. Several healthcare systems, including the Geisinger Health Care System as well as Utah’s Intermountain Health Care, Cleveland Clinic and Mayo Clinic, were cited. Many of the strategies that have been successfully incorporated by these institutions have been noted to lower healthcare costs. These include standardization of procedures and protocols, concentration on eliminating variance, and physician ownership of reform and are strategies we have incorporated at Valley Medical Center. Ten years ago we started the first Joint Center in Western Washington, which consisted of a dedicated hospital wing to total hip and knee replacements. From that start in 2000, we have evolved to a Center that has standardized preoperative and postoperative pathways for the care of total hip and knee replacement patients. By using a structured pathway with multimodal pain management, incorporation of a variety of different anesthetic techniques, and experienced nurses and therapists, we have been able to reduce variance with regard to recovery and therefore have an 85% discharge to home postoperative pathway. Our average length of stay is less than 3 days for a hip replacement and approximately 3 days for a knee replacement. By controlling the process from start to finish and minimizing variance we have cut down on outliers, reduced the cost of delivery of care, and have been able to maintain a center that is focused on quality and patient satisfaction.