In terms of getting the heat out of the case I think the ref cooler does a pretty decent job, I agree it's not subtle but it does get the job done at least for me anyway.
Again i wouldn't agree , if you're an average user and you dont mess about tweaking then you're going to put the card in the system and install the drivers and thats all you're going to do, in this scenario the ref card will usually (dependent on load) rockets up to 92 degrees and throttles as needed to keep the temps and noise in check , so in my humble opinion it barley gets the job done, and at a cost. This is why AMD added the extra control in ccc, so YOU as a user get to choose if you want it quiet and hot or not quite so hot but much louder.
I'm with funt darket, using two ref cards here. They do an excellent job at getting the heat out of the case. They do require some tweaking to get them running below 90C though. That tweaking involves changing the fan profile or lowering the voltage. Both of which are fairly easy (in my opinion) to anyone with a modicum of intelligence.