Multiple studies support the intuitive association between higher provider procedure volume and better clinical outcomes. Health care purchasers and payers have been seeking ways to direct patients to high-volume providers to improve the quality of care received and to avoid costs associated with higher surgical morbidity. Volume-based referral has faced resistance from providers who are concerned that the use of volume instead of more direct measures of surgical quality will result in unfair discrimination. On close examination, volume-based referral policies also appear to be more congruent with payers' interests than the interests of individual patients and providers. Furthermore, a policy of volume-based referral does not address surgical quality directly, is applicable to only a very small segment of surgical care, and is logistically problematic. However, in the absence of viable alternative measures of surgical quality, imperfect proxies such as volume will likely continue to be a significant part of the national dialogue surrounding surgical quality.