tion. Most employers fall at various points in between these extremes, although the general trend has been toward more involvement or at least more active oversight. Neither employers nor their environments are static, so a report such as this one necessarily provides only a snapshot of the proverbial moving target.

This section reviews some of the decisions, tasks, and options faced by those responsible for the design and maintenance of employers' health benefit programs, considers sources of diversity in the actions taken, and briefly describes some of the organizations that supply various kinds of services to employment-based programs. The next section presents a partly real, partly hypothetical case study that attempts to provide a more vivid sense of the policy, technical, and interpersonal challenges that can be involved in offering employees a health benefit program. A subsequent section selectively contrasts this core case with the situations faced by one much smaller organization and one much larger organization in order to illustrate further the diversity of employer and employee situations and the tangled issues of equity that employers and employees confront in considering various options. The final two sections examine how the roles of employees and health care providers in health benefit management are particularly affected by the link between employment and health benefits.

Types of Decisions, Tasks, and Options

In considering the advantages and disadvantages of employment-based health benefits, it is important to understand what responsibilities and tasks may be assumed when an organization decides to offer employee health benefits. Building from the discussion in Chapter 3, Table 4.1 depicts major categories of decisions and options that employers may face once they make the fundamental decision to offer health benefits. As will be made clearer shortly, not all items are relevant for all employers.

Sources of Diversity in Program Design and Management

What information, organizational characteristics (e.g., demographic structure of the work force and site[s] of operations), and principles guide employers' decisions about the design and operation of health benefit programs? How much do employers rely on consultants, brokers, and other outsiders? How are day-to-day matters managed, for example, the monitoring of plan utilization and expenses and handling employee complaints or problems? What tax, antidiscrimination, insurance, liability, and other legal constraints or concerns must be considered? What is involved in changing a health benefit program?

Answers to these questions are far from straightforward—as might be



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