Editor's note: In 1988, four Twin Cities business leaders formed the Buyers Health Care Action Group, a coalition of employers frustrated by the constantly rising cost of health insurance. The group now has about 40 members, including Target, Best Buy and Cargill, and has launched a number of initiatives to improve quality and control cost. Last week, Star Tribune health editor Dave Hage asked the group's president, Carolyn Pare, what employers think of the current health care debate in Washington.

Q Congress is considering an employer mandate called "pay or play.'' It would require most companies to offer health insurance to their employees or pay a fee to the government to pay for expanding coverage. What are local employers saying about that?

A Any time there's a government mandate, it increases the administrative burden on employers. Suddenly your benefits staff is dedicating its time to compliance as opposed to innovating and working on the true focus of the game -- improving health and health care.

Q But in a country that relies on employer-based health insurance for most people, how do we get to universal coverage without mandates?

A I don't think we'll ever get to universal health care until we fix the fundamental flaws in the system right now. All the conversation so far has been about expanding insurance and how to pay for that. But we need to be talking about improving quality and reducing wasteful care, not just paying the way we do now for overuse of care.

Everyone agrees that we should get to universal access. But if we could just wring out waste in the system right now -- if we paid for the right things instead of the wrong things and the unnecessary things -- we would have the resources to expand access.

Q If you had President Obama's ear, what advice would you give him on health care reform?

A There has been some discussion of quality, but not enough. There has been some discussion of payment reform, but not how to do it.

One of the big things missing has been the employer's voice. Self-insured employers have been excellent examples of innovation. They have a vested interest in keeping their employees healthy and contributing to the health of the community from which they draw employees.

Q Can you give an example?

A In 2006 we launched a pay-for-performance project, Bridges to Excellence, in conjunction with local employers and the Minnesota Council of Health Plans. We came up with evidence-based practice standards for three common complaints -- diabetes first, then vascular disease and then depression -- and posted information on how various health care providers meet those metrics. Consumers can find that information through the Minnesota Community Measurement website and compare providers. We also pay financial rewards to providers who hit all five standards of care. It now includes all the local health plans and, thanks to the Minnesota Department of Human Services, the entire managed-care population in the Medicaid program.

Q Has it improved care or caused consumers to shop around?

A I don't think we've publicized it enough to change consumer behavior, but clinics are comparing themselves to each other and trying to be the best providers. When we started, for example, only 5 percent of diabetes patients were getting optimal care. Now it's 14 to 18 percent, and at some clinics it's 50 percent.

Q Has it cut costs? Premiums in Minnesota don't seem much lower than premiums anywhere else.

A There are lots of ways of measuring costs. But employers wouldn't be investing in these things if they weren't seeing results.

Q What else has been missing from the debate in Washington?

A The consumer's voice. The only time we talk about the individual is when we talk about how they need to have skin in the game and adopt healthier behaviors. There's very little discussion of the tools and information we could give them to be good health care consumers and make the right decisions.

Q Can you be more specific?

A I don't see any effort to give people access to useful information -- the true cost of drugs, for example. People need to know that there is tremendous variation in cost and quality in the system. We've taught them to believe that everything costs the same and they have the right to demand everything they want to "get better.''

The reality is that there are some procedures that won't make them any better, but they don't have the information to think more critically about what will work for them and to evaluate what is being offered to them.

Dave Hage 612-673-4435