payers, however, are limited partly because of the expense and complexity of technology assessment and partly because they cannot fully capture the benefit of their work, the results of which can be used by their competitors (the ''free rider" problem). Reflecting the growing perception that the federal government needed to bolster its involvement in effectiveness research, Congress created the Agency for Health Care Policy and Research in the Department of Health and Human Services in 1989 and gave it broad responsibilities to develop practice guidelines and conduct research on the effectiveness of alternative forms of care for specific clinical conditions.

Although much of the interest in health status and outcome measures has come from either national policymakers or clinicians, employers and unions in a number of communities are becoming involved in pragmatic efforts to apply these measures, often with the support of private groups such as the John A. Hartford and Robert Wood Johnson foundations. Employers and unions are working with researchers, providers, and public officials to find practical ways to gather better data on outcomes and then use this information to improve the quality and efficiency of care (Borbas et al., 1990; Geigel and Jones, 1990; Madlin, 1991a; Stern, 1991; Buck, 1992; Mulley, 1992). Such efforts are under way in communities in Iowa, Minnesota, Ohio, Tennessee, and elsewhere.

The United States is clearly a leader in the arena of effectiveness research and technology assessment. Whether employers are, at the margin, providing any extra stimulus to effectiveness research and methodology development (beyond what government, private foundations, and some insurers would provide) is hard to say. Undoubtedly, many employers focus on costs and little else. Arguably, however, some large employers and employer coalitions may be encouraging a speedier movement from the research to the application stage for effectiveness assessments. Furthermore, a greater level of interest in local, communitywide assessments of provider performance may exist now than would be the case were employers uninvolved in health benefits.

Nonetheless, the challenges in devising good measures of outcomes and effectiveness, collecting accurate data, making fair comparisons, and doing it all at a cost perceived as reasonable are enormous. Given the complexity of medical care processes and the problem of controlling for the impact of economic, ethnic, and other variables on health, difficulties will surely continue for efforts to link many health care services—and expenditures—to specific outcomes. In addition, better measurement of health care outcomes and performance and programs to judge and improve the appropriate use of new or existing technologies may add to the cost—broadly defined—of administering health benefits. Like any other costs, these should be judged by whether and how much they help improve the value of health spending,

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