in the best position to influence costs, 23 percent cited doctors, 20 percent nominated insurers, and only 14 percent mentioned individuals.

  • Eleven percent of respondents said that they or a family member had foregone a job opportunity or stayed in a job because of health benefits. Those reporting such "job lock" said that another employer either did not offer health benefits, provided less generous benefits, offered a plan that would be too costly, or restricted coverage for preexisting conditions. The young, less educated, and middle class were the most likely to be affected.

  • A minority of respondents reported one or more negative experiences with cost management programs. Seventeen percent thought they had experienced unreasonable hassles or delays, 16 percent said they had to receive care from a physician they would not have chosen, and 9 percent thought they had been denied needed care.

  • About 1 respondent in 10 said most of their health plan was hard to understand, over one-third said some of it was hard to understand, and half said it was easy.

A system that links health benefits and employment clearly adds an additional layer of complexity and variability for both employer and employee over that which would exist with a unified national health insurance system. In comparison with the current market for individually purchased insurance, the employment-based system increases the burden on employers. However, it almost certainly reduces the decisionmaking and monitoring burden on most employees, although it can increase complexity or pose problems under some circumstances (e.g., part-time work and change of employment). The consequences for employees of employment-based health benefits may be both positive and negative, depending on the circumstances, philosophies, and choices of specific employers and on the leverage employees have within different organizations.

CONSEQUENCES FOR PRACTITIONERS AND PROVIDERS

Twenty years ago, or even 10 years ago, most physicians, hospitals, and other health care providers might have kept track of Medicare, Medicaid, and Blue Cross and Blue Shield plan requirements, filed information on the specific health benefit plans of dominant local employers (e.g., steel or auto companies), and—less commonly—contracted with one or two network health plans. These arrangements were not necessarily simple. They might involve complicated cost reimbursement or usual, customary, and prevailing reimbursement methodologies, auditing requirements, variations in coverage, and utilization review requirements. In 1959, even before Medicare, an official with the Kaiser Foundation Health Plan could note that "'it may be fashionable in some quarters to speak of the third party in medical care



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