President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry

Strengthening the Market To Improve Quality

Chapter Six
Encouraging Action by Group Purchasers

Group purchasers are a prominent feature of the U.S. employment-based health care marketplace. These entities -- private employers, union-sponsored multi-employer plans1, and Federal, State, and local governments -- enter into agreements with health plans or provider groups to provide health care to their individual members. As intermediaries between their members and the health plans, group purchasers make decisions on behalf of their employees or beneficiaries, such as (1) what health benefits to purchase; (2) what portion of the care is to be paid by the employee/beneficiary; and (3) the number and types of health plans with which to enter into agreements. To the extent that group purchasers make these decisions with attention to quality as well as cost (value), they can be a considerable force for quality improvement.


Group Purchasers

Most individuals in the United States who have health insurance secure it through group purchasers. In 1995, more than 83 percent of the insured population was covered by private insurance, mostly employment-based programs, while about 31 percent were enrolled in public insurance programs (i.e., Medicare, Medicaid, and CHAMPUS/CHAMPVA). As shown in Table 1, private group purchasers accounted for more than $206 billion in health care expenditures, the Federal Government nearly $240 billion, and State and local governments more than $241 billion. Although the combined power of these group purchasers in the marketplace could be a strong force for quality improvement in the health care industry, some group purchasers face impediments in fulfilling this role.

Impediments to Value-Based Purchasing

"Value-based purchasing," purchasing based on both price and quality considerations, is widely regarded as the standard for health care purchasing strategies (The Business Roundtable, 1997; Meyer, Rybowski, and Eichler, 1997; Schauffler and Rodriguez, 1996). However, some group purchasers confront obstacles to fully exercising this purchasing strategy. These include small private purchasers, Medicare, and State Medicaid agencies.

Table 1: Health Care Purchasing Expenditures, by Type of Group Purchaser*, 1995
(In billions)
Private Employers
Employer Contributions to Private Health Insurance Premiums
Employee Contributions to Employer Health Insurance Premiums** N/A
Workers Compensation and Disability 19.3
In-Plant Health Services 3.3
TOTAL 206.4+
Federal Government
Employer Contributions to Private Health Insurance Premiums
Employee Contributions to Private (Group) Health Insurance Premiums 3.9
Medicare Expenditures (excluding administrative costs) 183.9
Other Federal Health Care Expenditures*** 40.7
TOTAL 239.8
State and Local Governments
Employer Contributions to Private Health Insurance Premiums
Employee Contributions to Private (Group) Health Insurance Premiums** N/A
Medicaid Expenditures (excluding administrative costs) 133.1
Other Health Program Expenditures 61.1
TOTAL 241.3+
Source: Health Care Financing Administration, Office of the Actuary.
* Employer contributions to the Medicare Hospital Insurance Trust Fund are not funds that employers use to purchase health care and therefore are not included in the estimates of employer purchasing costs. Similarly, the Federal share of Medicaid has been assigned to States, since it is States that purchase Medicaid services. Multi-employer, union-sponsored plans are included in the category "private employers," and are estimated to account for about 5 percent of the workers who hold health insurance through their employment (National Medical Expenditure Survey, 1987).
** N/A: Employee data are not available separately for private industry and State and local governments.
*** Includes maternal and child health, vocational rehabilitation, Substance Abuse and Mental Health Services Administration, Indian Health Service, Federal Workers Compensation, and other miscellaneous general hospital and medical programs, public health activities, Department of Defense, and Department of Veterans Affairs.

Offering Consumers Choice

As documented in
Chapter 7, individual consumers2 and their families constitute the largest single source of money purchasing health care in the United States. If the marketplace power of this $310 billion to protect and improve health care quality is to be maximized, the individuals who control the use of this money will need to be able to exercise their judgment and preferences as consumers and choose among competing providers, products, and health plans.

Historically, "plans" and "products" were one and the same. HMOs offered only HMO products and insurance companies offered only indemnity products. In recent years many health plans have diversified and now offer multiple products. For example, HMOs have begun to offer POS products and indemnity insurers have created their own HMO products.

With respect to consumer choice of health products, an analysis of the 1996 KPMG Survey of Employee Health Benefits found that 56 percent of employees were offered multiple types of products (called "plan types" in the survey) (i.e., they were offered a combination of either HMO and conventional products, PPO and POS products, an HMO and some "other" product, or some other combination of products). An additional 36 percent of employees are offered only one health insurance product, but one that allows employees to receive care from "non-network" providers (i.e., a PPO, POS product, or a conventional product). When the percentage of employees who are offered either these multiple combinations of products or a single product that offers a non-network component are added together, 92 percent of all workers are found to have a choice to use network or non-network providers (Barents Group, 1997). An analysis of the March 1996 Current Population Survey by the Employee Benefits Research Institute found that in 1995, 77 percent of the privately insured population of the United States received their health care through a health care product that allowed access to non-network providers (i.e., a PPO, fee-for-service, or POS-HMO product) (EBRI, 1997).

Clearly, through the development and offering of innovative products such as POS products and preferred provider organizations, the health care marketplace has done much to facilitate consumer choice of providers. But it is important to recognize that for some consumers, accessing out-of-network providers may have significant financial consequences in terms of higher cost-sharing. Also, using an out-of-plan option as the primary vehicle for creating consumer choice may conflict with the goal of relying upon health plans to pursue quality-enhancing initiatives.

Health services research has not yet well measured the different levels of health plan choice offered consumers. While research has been conducted that attempts to measure the extent to which consumers have a choice of "plan," often the data obtained actually measures the availability of "products." For example, while the 1997 KPMG Health Benefits Survey concluded that "Since 1989, employers have significantly reduced the overall number of plans from which workers may choose," KPMG also notes that its "data may overstate the true degree of choice employees have available. If one managed care organization offers an HMO, conventional, and PPO plan to an employer, we would count this as three offerings" (KPMG, 1997). This blending of plan and product choice is also found in other surveys of consumer choice (Cantor, Long, and Marquis, 1995), making it impossible to assess trends in choice of plan.

However, one can identify the percentage of consumers who have no choice of plans. This is indicated by the percentage of consumers who have only one plan offered to them. Regardless of whether a survey actually measures plans, products, or both, the availability of only one health insurance coverage option can reasonably be interpreted as only one plan. The KPMG Peat Marwick Health Benefits Survey indicates that from 1989 to 1997, the percentage of employers with 200 or more workers offering only one plan grew from 36 to 44 percent (KPMG, 1997). Among midsize employers, 53 percent offered only one plan in 1996 (Gabel, Ginsburg, and Hunt, 1997). Other surveys indicate that about 40 to 50 percent of employees work for an employer who offers only one health plan (Cantor, Long, and Marquis, 1995).

The extent of employee choice often depends upon employer size; 32 percent of employers nationwide are estimated to offer only one health plan to their employees, but this varies from about 89 percent of very small firms (1 to 24 employees) to about 9 percent of very large firms (5,000 or more employees) (Gabel, 1997).

There are many legitimate reasons why a group purchaser may wish to contract with a single health plan. As discussed above, some employers find that a health plan or third-party administrator will give them a better price if they sign a "sole source" contract. Such contracts also tend to protect health plans and employers from adverse selection (KPMG, 1997), which can result when a given health plan disproportionately attracts sicker employees. If not adequately reimbursed for caring for sicker patients, such health plans are adversely affected (see Chapter 8).

Offering more than one health plan often is accompanied by greater costs to a group purchaser. For example, the cost of preparing materials for assisting individual members to choose between the plans, administering additional premium payment systems, and evaluating and providing ongoing incentives for quality improvement to two contractors will very likely be higher than the cost of offering one health plan.

While the leading group purchasers who already offer more than one health plan may have found this to be a cost they are able to accommodate, many group purchasers, especially small employer purchasers, may not be able to bear these additional costs. In addition, leaders in the industrial quality improvement movement have long urged producers to "move to a single supplier for any one item" (Deming, 1995). If an organization identifies the health care of its employees as one of its central services, and if employers treat the purchase of health care as they do their other large service contracts -- and recent evidence suggests that some leading purchasers are doing just that (Wall Street Journal, 1996) -- more employers may reasonably seek to offer fewer health plans to their employees.

Because of this, and because the marketplace has developed innovative products that offer consumers greater choice of providers, some may question whether offering consumers a choice of competing health plans is necessary. It could be argued that consumers value most their relationship with individual providers, and may not need or desire a choice of health plans as long as the product(s) offered allow access to desired providers. It could further be argued that group purchasers' selection of health plans based on quality will be a strong enough marketplace stimulus to improve quality and that additional selection of health plans by consumers offers few additional marketplace incentives to improve quality. However, when seeking to improve quality through the use of market forces, there also may be legitimate reasons why consumers may benefit and quality can be improved if consumers have a choice, whenever possible, of competing health plans.

The hallmark of a healthy marketplace has been defined by economists as one that allows consumers to "vote with their dollars" for the products of competing sellers (Friedman, Bailit, and Michel, 1995; Samuelson and Nordhaus, 1994). Providing them with a choice between two competing health plans allows consumers to financially "weigh in" in the marketplace for health plans and more directly influence how health plans develop their products and services. Further, because how a health plan performs in one dimension of quality cannot indicate how it will perform in others (Brook, McGlynn, and Cleary, 1996), a given health plan may not address the needs of all consumers equally well. For example, if one health plan performs well on preventive care, but another excels on care to the chronically ill, group purchasers and consumers will need to determine which aspect of quality they value more highly, and the answer may not always be the same.

Increased consumer responsibility for selecting a plan may also be appropriate in light of the increased responsibilities consumer have for health care costs. As described in Chapter 2, employees are increasingly being asked to share a greater portion of the costs of their health care premiums (GAO, 1997a). From 1992 to 1996, employees' dollar contribution to premiums increased at an average annual rate of 7.2 percent, while premium costs overall increased only 3.8 percent (Ginsburg and Pickreign, 1997). From 1988 to 1996, the portion of the premium paid by employees for family coverage rose from 26 to 30 percent. For individual coverage, the employee share rose from 10 to 22 percent (Jensen and Morrisey, 1997).

In addition to assuming increased responsibility for costs, consumers increasingly are being asked to assume greater responsibility for their health care decisions. The Consumer Bill of Rights encourages consumers to be responsible for (among others), "becoming involved in specific health care decisions. . . . recognizing the reality and limits of the science of medical care, and . . . the health care provider's obligation to be reasonably efficient and equitable in providing care to other patients and the community. . . . becoming knowledgeable about plan coverage and health plan options, including all covered benefits, limitations and exclusions, rules regarding use of network providers, coverage and referral rules, appropriate processes to secure additional information, the process to appeal coverage decisions, and reporting wrong-doing and fraud to appropriate resources and legal authorities." The Consumer Bill of Rights and Responsibilities also states, "The right to information will improve health outcomes only to the extent that consumers have a choice of health plans and use that information in exercising their choice."

Allowing consumers to exercise choice at the level of the health plan (especially when health plans provide substantial "value added" (see below) is consistent with initiatives to encourage greater responsibility by consumers.

Providing consumers with a choice of health plans, in addition to a choice of provider, acknowledges that health care quality is not just a function of the individual and organizational providers that make up a health plan. Health plans provide "value added." They do this by performing many activities that can directly affect consumers' health care and health care costs, such as employing mechanisms to promote evidence-based health care and technological advances, constructing disease management protocols to care for individuals with complex, acute, or chronic illnesses; developing patient care management tools such as patient reminder systems and disease registries; and developing powerful information systems that allow the health plan to strongly monitor and improve the health care delivered to their members. Because health plans bring such "value added" to health coverage purchased by consumers, not all health plans are alike, even if their provider networks greatly overlap. Allowing consumers a choice between two competing health plans acknowledges these differences and encourages consumers to select based on the plan features and attributes important to them. In this way consumers can serve as a stimulant to development of improved quality management practices by health plans.

These considerations support the position asserted in the Commission's Interim Report. The Consumer Bill of Rights and Responsibilities states that "Consumer choice of health plans is important and should be provided whenever possible and in a way that is affordable both to employers and consumers."

These considerations, in addition to those compelling reasons why group purchasers may wish to put some limitation on the amount of choice available, suggest the need for a balanced approach to consumer choice of plans. Specifically, while most group purchasers may not find it desirable or feasible to offer three, four, five, or more competing health plans, offering consumers a choice of two competing health plans can address the need for consumer choice of plans.

When it is not possible for a group purchaser to offer any choice of health plans to its individual members, group purchasers can provide group members with input into plan selection. Group purchasers have numerous options available to obtain input from employees regarding their preferences for specific health plans and products, and some employers are already exercising these options. Ryder System has undertaken such activities by involving its employees in the process of selecting the health plans to be offered (The Business Roundtable, 1997). Multi-employer (Taft-Hartley) health plans have elaborate structures for members' input since Federal law requires that there be equal representation of the covered employees and contributing employers in the administration of the plan. As a result, representative employees are directly involved in determining the amount of "choice" to be provided in consideration of the tradeoffs to be made between cost and choice.

Some employers are maintaining or expanding their ability to offer a choice of health plans to their individual members by joining a coalition of purchasers (Hoy, Wicks, and Forland, 1996; Drury, 1997). Joining a coalition of purchasers also has enabled some small purchasers to offer insurance where it has been previously unaffordable; pursue value-based purchasing in the marketplace; and employ mechanisms to promote accountability by their health plans for health care quality. Consumer-choice purchasing coalitions have been possible only in States that have achieved a certain degree of insurance reform, including limitations on rate adjustment based on health status, and modification of "fictitious group" laws that may have had the unintended consequence of preventing consumer-choice purchasing groups (Curtis and Haugh, 1996). These voluntary purchasing alliances/coalitions/groups face a number of other obstacles, which can impede their growth. These include such issues as the need to work with local insurance agents and the additional costs that offering health insurance will incur for small employers who previously did not offer insurance to their employees (Curtis, 1998). In addition, coalitions also face high development costs, estimated to be in the range of $500,000 to $600,000 for the first year. These efforts typically are not funded by charitable, grant-making foundations, because coalitions do not qualify as 501(c)3 organizations. In addition, some Federal tax policies may unnecessarily impede the formation and growth of some purchasing coalitions.

In spite of these difficulties, the Employees Benefit Research Institute documents that 17 States have established voluntary health alliances (the majority located in the private sector) for the purpose of allowing small groups, acting together, to gain the bargaining power and economies of scale enjoyed by large groups (EBRI, 1997). While not a panacea, health care purchasing coalitions can make and have made contributions by assisting some small group purchasers to offer a choice of competing health plans to their individual members and potentially achieving the same economies of scale and ability to undertake value-based purchasing that are more readily available to larger group purchasers.

Selection Based on Quality and Cost

A variety of approaches can be used by group purchasers to incorporate quality into their plan selection processes. GTE Corporation uses HEDIS data as one factor in determining the health plans with which it will contract. Xerox Corporation ranks health plans based on accreditation status, quality indicators, and satisfaction ratings and provides this information to employees during open enrollment periods. ARCO evaluates health plans using 50 weighted quality and access criteria and sets its employer contribution to the premium level of the highest ranking plan. The Arizona Medicaid program assigns a weight of about 70 percent to quality and access criteria and 30 percent to cost in evaluating potential health plan contractor proposals, and in 1994 awarded contracts to 14 of 21 bidders (GAO, 1997b).

Although significant progress has been made, available information on the practices of group purchasers indicates that some are not yet following the lead of these and other group purchasers. In a survey of 33 large purchasers in California; New York; Cleveland, Ohio; and Pennsylvania, who were responsible for more than 1.8 million lives, 45 percent reported using HEDIS data, 55 percent reported using accreditation data, and 53 percent reported using consumer satisfaction survey data to choose a health plan. Only 25 percent reported using hospital performance measures when they were available to them. Further, only 20 percent of survey respondents had explicit decision criteria and approaches for using the quality data and consistently integrating and weighing competing factors (Hibbard et al., 1997). Results from another 1997 survey of 325 U.S. companies found that although most employers consider provider network characteristics (e.g., geographic accessibility, credentials, privileges) along with cost and utilization data, far fewer have considered more quantifiable measures of quality such as HEDIS data, medical outcomes, and audited report cards. (Washington Business Group on Health and Watson Wyatt Worldwide, 1997).

In an examination of purchasing strategies in 15 communities, it was found that only a small group of large and prominent employers are using quality data to make health plan selections (Lipson and De Sa, 1966). Another survey (Lippman, 1966) of executives of companies with 20 or more workers found that when asked to divide 100 points among five decisionmaking factors in selecting health plans, replies were 33 points for lowest rates (prices); 25 points for wide choice of primary care physicians; 15 points for performance against standardized quality measures; 14 points for convenient access to specialty care; and 13 points for accreditation. The 1997 KPMG Health Benefits Survey of employers with 200 or more workers finds that, "In selecting a health plan, employers continue to make their decisions on traditional concerns -- cost, customer service, and the physicians in the provider network -- rather than measurable standards of quality or NCQA accreditation. Nearly two-thirds of midsize and large employers are unfamiliar with NCQA accreditation" (KPMG, 1997).

The limited practice of purchasing based on quality is attributed to "the growing complexity of the provider market, the difficulty in deciphering new rating and accreditation standards, the burden of annual negotiation of multiple contracts, the lack of effective and standardized outcome and treatment data, and wide disparities in local and regional norms for what constitutes value, quality and accountability" (Washington Business Group on Health and Watson Wyatt Worldwide, 1997). Other identified reasons include the lack of awareness of available information on quality, lack of purchasers' understanding of quality measures, lack of "packaging" of quality information to meet purchasers' needs, and lack of decision support tools to aid purchaser decisionmaking (Hibbard et al., 1997).

Sharing Information With Consumers

Like group purchasers, individual members of purchasing groups will need information on quality to make their own purchasing decisions. Individual members may reasonably look to their group purchasers to provide them with information on the quality of health plans available to them. A number of large group purchasers are responding to this need. To help employees judge which plan best meets their needs, Digital Equipment Corporation publishes a report card for its employees. AT&T, together with its unions (the Communications Workers of America and the International Brotherhood of Electrical Workers), produces an annual report card which details health plan service and clinical performance in comparison to industry normative data (The Business Roundtable, 1997).

However, as discussed above, access to and use of such measures by group purchasers is not yet widespread; consequently it is not surprising that employers provide few comparative quality data to their employees. In the Watson Wyatt/Washington Business Group on Health survey, the majority of employers reported providing employees with information on "how to use a plan," service locations, and cost and benefits comparisons; 10 percent or fewer provided employees with report cards, HEDIS, or medical outcomes data. In another survey of 33 large employers that purchase for 1.8 million lives, 78 percent of purchasers reported that HEDIS data were available to them, 54 percent reported using it for choosing a plan, and 31 percent provided performance measures to their employees (Hibbard et al., 1997).

Although a number of large group purchasers are undertaking consumer information initiatives, it is probably unrealistic and perhaps undesirable to expect all group purchasers to assume the primary responsibility for obtaining comparative quality data from health plans, and analyzing and presenting it to consumers. As discussed in Chapter 7, the provision of valid and useful information to consumers is labor-intensive and costly. In addition, a number of surveys and focus groups have shown that consumers place a very high value on the credibility of the source of information. In the Kaiser/AHCPR survey, 58 percent of those surveyed agreed that "employers were not a good source of information about the quality of health plans because employers' main concern is to save money on health benefits" (Robinson and Brodie, 1997). The same conflict between cost-saving and quality also exists in the Medicaid and Medicare programs.

However, all group purchasers can provide their employees or beneficiaries with the information on quality, cost, and other factors that led to their decision to offer certain health plans. The information that consumers will need to assess quality and make their own purchasing decisions will vary accordingly. For example, if a consumer felt reasonably assured that the health plans offered were selected with substantial attention to overall quality, the consumer could focus attention on other concerns, such as services pertaining to specific clinical conditions, accessibility of providers, specific practitioners within the plan, etc.

Stimulating Quality Improvement

Subsequent to the decision to select a source of health care coverage for their individual members, purchasers also can pursue additional steps to contribute to improvements in quality over time, including providing financial incentives to improve performance; undertaking collaborative projects in partnership with their health plans; and supporting community, State, and national activities to improve quality. The Business Roundtable has documented numerous such quality improvement initiatives undertaken by leading U.S. corporations (The Business Roundtable, 1997). Examples of how these and other purchasers have undertaken such initiatives are:

In summary, not all group purchasers have the resources to participate in community-based quality improvement initiatives like the ones mentioned above. However, nearly all communities have local public health initiatives to improve health care and health care quality (e.g., childhood immunization campaigns, cancer screening programs, and health education programs) in which group purchasers, even small group purchasers, could participate even if their participation is limited to informing their employees about available free services.


Barents Group LLC, Characteristics of Health Plan Choices Available to Employees Through Employer-Based Health Benefits 1996 (Washington, DC: June 18, 1997).

Brook, Robert H., Elizabeth McGlynn, and Paul D. Cleary, "Quality of Health Care, Part 2: Measuring Quality of Care," New England Journal of Medicine 335(13):966-970, September 26, 1996.

The Business Roundtable, Quality Health Care Is Good Business (Washington, DC: September 1997).

Cantor, Joel C., Stephen H. Long, and M. Susan Marquis, "Private Employment-Based Insurance in Ten States," Health Affairs 14(2):199-211, Summer 1995.

Census Bureau, Department of Commerce, Program Research and Methods Branch, tabulations prepared under contract to the Small Business Administration, 1997.

Cowan, Cathy A., Office of the Actuary, Health Care Financing Administration, telephone conversation, October 1997.

Curtis, Richard A., Institute for Health Policy Solutions, testimony before the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry, January 28, 1998.

Curtis, Rick, and Kevin Haugh, "Small-Employer Co-ops Pick Up Speed," Business and Health 14(7):29, 31-34, 36, July 1996.

Deming, W. Edwards, Out of the Crisis. (Cambridge, MA: Institute of Technology, Center for Advanced Engineering Study, 1995).

Drury, Patricia, Buyers Health Care Action Group, telephone conversation, October 8, 1997.

Employee Benefit Research Institute (EBRI), EBRI Databook on Employee Benefits, 4th edition (Washington, DC: 1997).

Friedman, Meryl D., Michael H. Bailit, and James O. Michel, "Vendor Management: A Model for Collaboration and Quality Improvement," Journal on Quality Improvement 21(11):635-645, November 1995.

Gabel, Jon R., KPMG Peat Marwick, testimony before the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry, June 23, 1997.

Gabel, Jon R., Paul B. Ginsburg, and Kelly A. Hunt, "Small Employers and Their Health Benefits, 1988-1996: An Awkward Adolescence," Health Affairs 16(5):103-110, September/October 1997.

General Accounting Office, Management Strategies Used by Large Employers to Control Costs, GAO/HEHS-97-71 (Washington, DC: May 1997a).

General Accounting Office, Private Health Insurance: Continued Erosion of Coverage Linked to Cost Pressures, GAO/HEHS 97-122 (Washington, DC: July 1997b).

Ginsburg, Paul, and Jeremy Pickreign, "Tracking Health Care Costs: An Update," Health Affairs 16(4):151-155, July/August 1997.

Hibbard, Judith H., Jacquelyn J. Jewett, Mark W. Legnini, and Martin Tusler, "Choosing a Health Plan: Do Large Employers Use the Data?" Health Affairs 16(6):172-180, November/December 1997.

Hoy, Elizabeth W., Elliot K. Wicks, and Rolfe A. Forland, "A Guide to Facilitating Consumer Choice," Health Affairs 15(4):9-30, Winter 1996.

Hurley, Mary Lou, "No Firm Is an Island," Business and Health 14(11):57-58, 60, November 1996.

Institute of Medicine, Improving the Medicare Market: Adding Choice and Protections (Washington, DC: National Academy Press, 1996).

Jensen, Gail, A., Michael A. Morrisey, Shannon Gaffney, and Derek K. Listov, "The New Dominance of Managed Care: Insurance Trends in the 1900s," Health Affairs 125-136, January/February 1997.

Jensen, Gail A., and Michael A. Morrisey, Managed Care and the Small Group Market (Washington, DC: American Enterprise Institute, April 10, 1997).

KPMG Peat Marwick, Health Benefits in 1997 (Montvale, NJ: 1997).

Lippman, Helen, "Can Employers See Beyond Price -- Results of a 1996 Executive Opinion Poll," Business and Health 14(2):44-46, 50-54, 57, December 1996.

Lipson, Debra J., and Jeanne M. De Sa, "Impact of Purchasing Strategies on Local Health Care Systems," Health Affairs 15(2):62-76, Summer 1996.

Meyer, Jack, Lise Rybowski, and Rena Eichler, Employer-Sponsored Initiatives to Measure Quality: Evaluating Performance Records (draft) (Washington, DC: Agency for Health Care Policy and Research, June 1997).

Morrisey, Michael A., Gail A. Jensen, and Robert J. Morlock, "Small Employers and the Health Insurance Market," Health Affairs 13(5):149-161, Winter 1994.

Myers, Woodrow A., Ford Motor Company, testimony before the Subcommittee on Roles and Responsibilities of Group Purchasers and Quality Oversight Organizations of the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry, February 25, 1998.

Robinson, Sandra, and Molly Ann Brodie, "Understanding the Quality Challenge for Health Consumers: The Kaiser AHCPR Survey," Journal on Quality Improvement 25(3):239-244, May 1997.

Samuelson, Paul A., and William D. Nordhaus, Economìa, 14th edition (Aracava (Madrid): McGraw- Hill, 1994).

Schauffler, Helen Halpin, and Tracy Rodriguez, "Exercising Purchasing Power for Preventive Care," Health Affairs 15(1):73-85, Spring 1996.

Wall Street Journal, "Auto Makers Attack High Health-Care Bills With New Approach -- They Treat Providers Like Other Suppliers, Try to Help Them Cut Cost," December 9, 1996.

Washington Business Group on Health and Watson Wyatt Worldwide, Getting What You Pay For -- Purchasing Value in Health Care (Bethesda, MD: Watson Wyatt Worldwide, 1997).

  1. Union-sponsored multi-employer plans play an important role in providing health insurance in industries where workers are highly mobile, such as construction and building trades. Workers in these industries are often employed on a temporary basis (e.g., for the life of a particular construction project) and usually work for many different employers over the course of their careers.

  2. "Consumer" refers to all potential individual end users of health care (i.e., men, women, and children who receive the health services delivered by physicians, nurses, dentists, and other licensed and unlicensed health care providers).

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