Successful purchasing will require substantial changes from today's approach—and senior managers hold the key

Employers will continue to have a key role in the U.S. health system. Unfortu- nately, their purchasing practices have fallen far short of ideal. Large employers can lead the way for smaller companies, but by not routinely using competitive bidding or integrating quality into their specifications, they have sent mixed messages to both health plans and providers. Employers need to either get serious about buying health care as individual com- panies or explore other options. To purchase effectively, both health care expertise and the sustained commitment of senior leadership are needed. Whether employers can reverse their historical performance and become better purchasers is an open question.