gressive Policy Institute is that Medicare beneficiaries be given an option to join voluntary consumer cooperatives. James Firman and the National Council on the Aging have also proposed consumer cooperatives for Medicare beneficiaries. These cooperatives would have the power to negotiate on behalf of their Medicare enrollees with health plans on cost, quality, and other issues. They would be federally chartered, would offer a menu of options, and would be financed by a fixed percentage of the premiums that they handle. Multiple, competing cooperatives would be allowed, and beneficiaries would be able to decide whether to select their plans from the federal government's FEHBP-type arrangement or from one of the consumer cooperatives. In this approach, the voluntary consumer cooperatives, selected by beneficiaries, would assume the purchasing functions that government would take on in a previously described option. Compared with federally run purchasing arrangements, private sector cooperatives may have more flexibility and freedom from political pressures (Kendall, 1995).

Strengthen Professional Influences

Strengthening the influence of health care professionals who are committed to advancing clinical practice is a third strategy that could be used to promote health plan excellence. The following options are among the measures that could be considered.

Option #1. Provide a better clinical basis for medical care of the Medicare elderly and disabled population. At the American Association of Retired Persons' (AARP) 30th anniversary conference on Medicare, Robert Brook suggested a major national effort on clinical effectiveness and outcomes studies for the elderly. He noted that although many such studies are still needed for the population under age 65, the research literature is far more sparse for the population over age 65. Given the advances in research methods, his view was that this clinical knowledge could now advance rapidly. If health plan medical directors, accrediting agencies, health care professionals, report card designers, and Medicare enrollees are to perform their roles better, they need a far better scientific basis for their judgments.

IOM might be well suited for sponsoring a study by a com-

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