1 See generally Newhouse, Joseph, An Iconoclastic View of Health Care Cost Containment, Health Aff., Supp. 1993CrossRefGoogle Scholar, at 152 (emphasizing new technology as the major reason for health care cost increases).

2 Students of health policy have long observed that cost-benefit tradeoffs are inevitable. See. e.g., Eddy, David M., Health System Reform: Will Controlling Costs Require Rationing Services!, 272 Jama 324, 326 (1994)CrossRefGoogle Scholar (analyzing rationing mechanisms as a means to contain health care costs unavoidably driven up by technological advances); Aaron, Henry & Schwartz, William B., Rationing Health Care: The Choice Before Us, 247 Science 418, 418-19 (1990)Google Scholar (considering the benefits of technological advancements and their costs).

3 See Elhauge, Einer, Allocating Health Care Morally, 82 Cal. L. Rev. 1451, 1459 (1994)CrossRefGoogle Scholar (noting that the United States could easily spend 100% of its gross national product on beneficial medical interventions).

4 Managed care refers to organizational structures that integrate health care finance and delivery in a structured way that allows for oversight of the quality and cost *bf health care services. See Kenneth Wing, Michael Jacobs & Patricia Kuszler, the Law and American Health Care 83-84 (1998).

5 See Jensen, Gail A. et al., The New Dominance of Managed Care: Insurance Trends in the 1990s, Health Aff., Jan./Feb. 1997, at 125Google Scholar, 134. More than 75% of insured workers are enrolled in managed care plans. See id. at 125.

6 See generally Gold, Marsha et al., Behind the Curve: A Critical Assessment of How Little is Known About Arrangements Between Managed Care Plans and Physicians, 52 Med. Care Res. & Rev. 307 (1995)CrossRefGoogle Scholar (discussing the range of financial arrangements between physicians and health plans).

7 See Wing, Jacobs & Kuszler, supra note 4, at 84.

8 See Hall, Mark, A Theory of Economic Informed Consent, 31 Ga. L. Rev. 511, 517 (1997)Google Scholar. Six states have enacted laws that require managed care organizations (MCOs) to disclose their financial incentive plans. See id. at 517 n.16 (ARIZ. REV. STAT. ANN. § 20-1076 (West Supp. 1993); Ga. Code Ann. § 33-20A-6 (Supp. 1996); Me. Rev. Stat. Ann. tit. 24-A, § 4302 (1998); R.I. Gen. Laws § 23-17.13-3 (1998); Vt. Stat. Ann. tit. 18, § 9414 (1998); Wyo. Stat. Ann. § 26-34-109 (Michie 1995)). In addition, the U.S. Court of Appeals for the Eighth Circuit has held that administrators of health plans governed by the Employee Retirement Income Security Act (ERISA) have a fiduciary duty to disclose financial incentives imposed on physicians. See Shea v. Esenten, 107 F.3d 625, 628-29 (8th Cir. 1997). Other courts have declined to follow the lead of the Eighth Circuit. See, e.g., Weiss v. Cigna Healthcare, Inc., 972 F. Supp. 748 (S.D.N.Y. 1997) (rejecting the contention that ERISA's general fiduciary obligations require disclosure of financial incentives by the health maintenance organization (HMO)).

9 See Agrawal, Gail, Chicago Hope Meets the Chicago School, 96 Mich. L. Rev. 1793, 1816-17 (1998)Google Scholar (arguing that a “knowledgeable consumer of health care services searches in vain in the promotional materials for any statements conveying to the unsuspecting that the coverage or the medical care will be less than optimal.”).

10 Significantly, the relevant comparison must be between tradeoffs that the enrollee would have made ex ante (i.e., at enrollment) and those made by the physician and/or third-party utilization reviewer. If cost containment is the goal, the ex post preferences of insured individuals cannot be used. If an individual is fully insured, she has little incentive to consider costs.

11 This Article uses the term rationing to encompass cost-benefit tradeoffs generally, not simply cost-based denials of beneficial care by administrative bodies. See, e.g., Mark A. Hall, Making Medical Spending Decisions 6 (1997) (using the terms rationing and allocation interchangeably to denote the “implicit or explicit denial of marginally beneficial treatment out of consideration for its cost”). But see Havighurst, Clark C., Prospective Self-Denial: Can Consumers Contract Today to Accept Health Care Rationing Tomorrow?, 140 U. Pa. L. Rev. 1755, 1762-64 (1992)Google Scholar (arguing that the term rationing applies only to government decisions that limit the amount of beneficial health care individuals can purchase in the private market).

12 See discussion infra Part II. An issue that arises in discussions of explicit rationing concerns whether disclosures regarding such rationing need to be made only at the time of enrollment or should be made both at enrollment and when a specific, cost-based decision not to recommend certain services is made. Compare Hall, supra note 11, at 202-12 (arguing that disclosure and consent at enrollment represents consent to future cost-saving medical spending decisions) with Agrawal, supra note 9, at 1809-21 (arguing that disclosure is needed both at enrollment and at the time of the specific clinical decision). Because this Article addresses only the question of informed choice at enrollment, it does not focus on this issue.

13 For further discussion of this argument, see infra notes 57-58, 60-63 and accompanying text.

14 To be sure, information technology will only be useful to the extent that all individuals, including the poor and other underserved populations, have access to such technology. The Article assumes that public funding would play a role in ensuring such access.

15 See, e.g., Ellman, Ira Mark & Hall, Mark, Redefining the Terms of Health Insurance to Accommodate Varying Consumer Risk Preferences, 20 AM. J.L. & Med. 187, 188 (1994)Google Scholar (discussing “Cadillac” and “Chevrolet” care).

16 See id. at 189.

17 See id.

18 See id. at 193.

19 See id. at 193-94.

20 See id.

21 See Clark Havighurst, Health Care Choices 137-330 (1995).

22 Id. at 189.

23 Id. at 188.

24 See id. at 222.

25 Practice guidelines are standardized treatment protocols for particular conditions. See Rai, Arti, Rationing Through Choice: A New Approach to Cost-Effectiveness Analysis in Health Care, 72 Ind. L.J. 1015, 1058 n.185 (1997)Google Scholar. Since the late 1980s, the Agency for Health Care Policy and Research as well as various professional associations have been heavily involved in the development of these guidelines. See id.

26 See Havighurst, supra note 21, at 223.

27 See id. at 226.

28 See id. (stating that the guidelines carry “an immense potential for introducing cost considerations into medical decisions and for decentralizing decision-making responsibility.”).

29 See id. at 250.

30 Id.

31 Id.

32 See id.

33 See id. at 252.

34 See id. at 258-59.

35 See id.

36 See id.

37 See Elhauge, supra note 3, at 1524-25; Ezekiel Emanuel, the Ends of Human Life 139-44 (1991); see generally Rai, supra note 25, at 1032 (supporting the proposition that value, not income levels, often determines an individual's health choices).

38 See Tolley, George et al., State-of-the-Art Health Values, in Valuing Health For Policy: An Economic Approach 323, 330 (George Tolley et al., eds., 1994)Google Scholar.

39 See Rai, supra note 25, at 1030.

40 See Office of Technology Assessment, United States Congress, Evaluation of the Oregon Medicaid Proposal 10 (1992) (noting that the Oregon telephone survey demonstrated considerable individual differences in health state valuation).

41 See Rai, supra note 25, at 1030-35; Elhauge, supra note 3, at 1525-26; Emanuel, supra note 37, at 185-92.

42 See Rai, supra note 25, at 1037-38.

43 Medical cost-effectiveness analysis, which measures effectiveness in terms of “quality-adjusted life years” (QALYs), has been used since the mid 1970s. See Zeckhauser, Richard & Shepard, Donald, Where Now for Saving Lives?, Law & Contemp. Probs., Autumn 1976, at 5, 11CrossRefGoogle Scholar.

44 See id. at 15-17.

45 For a classic discussion of medical cost-effectiveness analysis, see generally Milton C. Weinstein & William B. Stason, Foundations of Cost-Effectiveness Analysis for Health and Medical Practices, 296 New Eng. J. Med. 716 (1977).

46 See Zeckhauser & Shepard, supra note 43, at 11.

47 For a discussion of this and other approaches to eliciting health state rankings, see Torrance, George W., Measurement of Health State Utilities for Economic Appraisal: A Review, 5 J. Health Econ. 1, 18-25 (1986)Google Scholar.

48 See id. at 22. Other mechanisms for measuring health state values include the ratings scale approach and the standard gamble approach. See id. at 18-22. The ratings scale approach asks interviewees to rate various health states on a scale of zero to one, where death is valued at zero and perfect health is valued at one. See id. at 18-20. The standard gamble approach asks interviewees what chance of death they would risk in order to avoid living in a particular diminished state of health. See id. at 20-22.

49 See Weinstein & Stason, supra note 45, at 718.

50 See id. at 721.

51 See id. at 719.

52 This figure, at least as calculated in 1991 dollars, is one that many health economists have used. See Robert Fabian, The Qualy Approach, in Valuing Health for Policy, supra note 38, at 118, 129.

53 To be sure, the practice of medicine is rarely as exact or predictable as the example in the text suggests. The simplification aids in conveying how cost-per-QALY analysis may work.

54 See supra notes 15, 37-42 and accompanying text.

55 See, e.g., Tom Beauchamp & James Childress, Principles of Biomedical Ethics 120-88 (4th ed. 1994) (discussing the history of autonomy in biomedical ethics); H. Tristram Engelhardt, the Foundations of Bioethics 102-34 (1996) (discussing the central role of autonomy in medical ethics). The moral philosophical literature on autonomy is voluminous. Autonomy is prized not only by deontologists, who consider self-governance to be central to personhood, see Immanuel Kant, Grounding for the Metaphysics of Morals 41 (James Ellington trans., 3d ed. 1993) (“Thereby is he free as .. . he obeys only those laws which he give to himself”), but also by utilitarians, who argue that an individual's assessment of her own welfare is more likely to be accurate than an assessment made by a third party. See John Stuart Mill, on Liberty 74 (Elizabeth Rapaport ed., Hackett Publ'gCo. 1978).

56 For a discussion of autonomy that focuses on the distinction between first- and second-order preferences, see Gerald Dworkin, the Theory and Practice of Autonomy 108 (1988). See also Elizabeth Anderson, Value in Ethics and Economics 162 (1993) (arguing that choice-based systems do not differentiate between “reasoned ideals” and “unreflective wants”).

57 See Emanuel, Ezekiel J. & Emanuel, Linda L., Preserving Community in Health Care, 22 J. Health Pol. Pol'Y & L. 147, 168 (1997)CrossRefGoogle Scholar; see also Greaney, Thomas L., How Many Libertarians Does It Take to Fix a Health Care System?, 96 Mich. L. Rev. 1825, 1831 (1998)CrossRefGoogle Scholar (arguing that “health care markets are uniquely plagued by informational deficits”); Susan*Edgman-Levitan & Paul D. Cleary, What Information Do Consumers Want and Need, Health Aff., Winter 1996, at 42, 53 (1996) (noting that “[m]any elements of information that consumers said would be useful [in choosing health plans] are complicated and difficult to present and interpret”). It bears mention, however, that the informational difficulties that are important for the purposes of this Article are not those specifically associated with making individual treatment decisions at the time of illness. In the specific context of individual treatment decisions, the patient must have particularized knowledge of the costs and benefits of various alternative medical treatments and must be able to make a rational decision despite the fact that she is ill. By contrast, in the context of a health insurance choice, a healthy consumer would be looking at different levels of, and/or methods for, economizing.

58 See Charny, David, Hypothetical Bargains: The Normative Structure of Contract Interpretation, 89 Mich. L. Rev. 1815, 1854-55 (1991)Google Scholar (noting that the application of the contra proferentum (against the proffering party) rule by courts is rooted in concerns about the nonproffering party's lack of meaningful choice or lack of information in accepting the bargain in question). For a discussion of various cases in which courts have construed exclusionary clauses in health insurance contracts extremely narrowly, see Hall, Mark & Anderson, Gerard, Health Insurers' Assessment of Medical Necessity, 140 U. Pa. L. Rev. 1637, 1645-47 (1992)Google Scholar.

59 See Havighurst, supra note 21, at 21-22. Another argument that could be made against choice is that, because of the collective nature of health insurance, it is unlikely that individuals would be able to find a rationing scheme that precisely reflected their every preference. Nonetheless, the limitations on individual preferences imposed by a choice-based framework would be less substantial than those imposed by a single, centrally administered rationing scheme.

60 See, e.g., Hibbard, Judith H. et al., Informing Consumer Decisions in Health Care: Implications From Decision-making Research, 75 Milbank Q. 395, 400 (1997)Google Scholar (noting that a “person in good health cannot always foresee what his or her needs or values might be during an illness”). For discussions of the analogous problem of adequate reflection in ex ante decisions regarding advance directives, see Teno, Joan M. et al., Do Advance Directives Provide Instructions That Direct Care?, 45 J. Am. Geriatrics Socy 508, 511 (1997)CrossRefGoogle Scholar; Susan Wolf et al., Sources of Concern about the Patient Self-Determination Act, 325 New Eng. J. Med. 1666, 1668 (1991); Allen Buchanan, Advance Directives and the Personal Identity, 17 Phil. & Pub. Aff. 277, 277-79 (1988). For a general discussion of problems with ex ante choices that bind for a long period of time, see Derek Parfit, Reasons and Persons 326-29 (1984).

61 See Norman Weinstein, Optimistic Biases About Personal Risks, 246 Science 1232-33 (1989); see also Amos Tversky & Daniel Kahneman, Judgment Under Uncertainty: Heuristics and Biases, 185 Science 1124, 1128-30 (1974) (noting that public reliance on common, generally reasonable, heuristics can lead to faulty predictions regarding uncertain events).

62 See Hibbard et al., supra note 60, at 398-99. Individuals are particularly confused by information about quality variables. See id. For example, with respect to a quality variable, such as a managed care plan's rate of mammography in women, individuals may fail to understand the concept of a rate, may erroneously believe that breast cancer is largely found in men or may erroneously believe that screening programs are not efficacious. See Jacquelyn Jewett & Judith Hibbard, Comprehension of Quality Care Indicators: Differences Among Privately Insured, Publicly Insured, and Uninsured, Health Care Fin. Rev., Fall 1996, at 75, 83.

63 See Hibbard et al., supra note 60, at 396-400 (discussing the effect of too much information on decision making).

64 See generally Leonard M. Fleck, Just Health Care Rationing: A Democratic Decision-making Process, 140 U. Pa. L. Rev. 1597 (1992) (positing the idea that health care rationing should be done through collective decision making).

65 See Anderson, supra note 56, at 142 (“Autonomy can be realized on a collective scale through democratic institutions. Collective autonomy consists in collective self-governance by principles and valuations that everyone, or the majority, reflectively endorses.”).

66 See Karen Davis & Cathy Schoen, the Commonwealth Fund, Managed Care, Choice, and Patient Satisfaction (Aug. 1997) (visited May 26, 1999) <http://www.cmwf.org/programs/health%5Fcare/satisbn.asp> (concluding that 48% of working Americans lack choice with respect to their health plans).

67 See supra notes 8-9 and accompanying text.

68 Compare Agrawal, supra note 9, at 1816-17 (“If selection of a health maintenance organization is intended to express a preference for 'less than optimal' medical benefit, consumers also may be affirmatively misinformed about the nature of their purchase.”).

69 See Renee Blankenau, Confused Consensus: When Given Options, What Health Plans Do Consumers Choose and Why, Hosp. & Health Networks 31, 31 (July 5, 1993). Employer willingness to pay for health insurance and employee willingness to accept such payment in lieu of higher wages stem, of course, from the federal tax subsidy for private health insurance.

70 Notably, even in a system that allows a wide range of choices, choices that seem clearly foolish or ill-considered might be barred. For example, ex ante rationing choices that contemplate serious and irreversible deprivations of liberty might be disallowed. See Gerald Dworkin, Paternalism, in Morality and the Law 107, 118 (Richard A. Wasserstrom ed., 1971) (arguing that paternalism can be justified when it preserves “a wider range of freedom for the individual in question”). Similarly, choices that bind individuals for excessively long periods of time, say over three to five years, could be barred: barring such choices would address the concern, .expressed by some commentators, that allowing individuals to make choices that bind their future selves is problematic, because individuals do not value their future selves sufficiently. See Richard A. Posner, Aging and old Age 91-95 (1995); Parfit, supra note 60, at 326-29.

71 The details of how these conditions would be satisfied are beyond the scope of this Article. For discussions of publicly funded schemes under which individuals would be given vouchers that they could use to choose among health plans with different approaches to rationing, see Rai, supra note 25, at 1035-48; Elhauge, supra note 3, at 1525-41; Emanuel, supra note 37, at 185-92.

72 See Rai, supra note 25, at 1039.

73 Such regulation could be adopted at either the federal or state level. For purposes of uniformity it may be advantageous to adopt the regulation at the federal level.

74 See Hibbard et al., supra note 60, at 407.

75 See id. at 403-04; see also Jewett & Hibbard, supra note 62, at 77 (noting that “big ideas” and concepts are much easier for individuals to understand than a large number of small facts).

76 See Jewett & Hibbard, supra note 62, at 92; Hibbard et al., supra note 60, at 405. It bears emphasis, however, that this question of “information overload”—whether consumers can make good choices when confronted with multiple alternatives that have many different attributes—is much disputed. For example, some researchers argue that the empirical evidence demonstrates that “information overload” is a myth. These researchers interpret the evidence as showing that, when consumers are faced with multiple alternative choices, each of which has multiple attributes, they choose appropriately by focusing on a small number of attributes that are salient to them—they “optimize.” See David M. Grether et al., The Irrelevance of Information Overload: An Analysis of Search and Disclosure, 59 S. Cal. L. Rev. 277, 279 (1986). Moreover, because salient attributes vary across consumers, “if a substantial number of consumers shop for attributes in which they are interested, the full set of salient attributes will be supplied at competitive price-quality levels.” Id. at 300-01 (citing Schwartz & Wilde, Product Quality and Imperfect Information, 52 Rev. Econ. Stud. 251 (1985)). Whether consumers do come up with good heuristic devices to negotiate through large amounts of information is not critical for the purposes of this Article; the layering approach suggested here provides a ready-made heuristic device for all consumers.

77 Although most health plans are currently not required to disclose information about how they ration care, see supra note 8 and accompanying text, there is precedent for requiring such disclosure. Hmos are, for example, required to disclose a wide variety of other information. See 42 C.F.R. § 417.124(b) (1996) (requiring “full and fair disclosure” of participating providers, service area, benefits and procedures to be followed in obtaining benefits). Moreover, Medicare regulations require that Mcos with physician financial incentive schemes disclose the existence of these schemes to beneficiaries who ask. See 42 C.F.R. § 417.124(b). Similarly, in areas other than health care, the government requires that contracting parties disclose information. See, e.g., Consumer Credit Protection Act, 15 U.S.C. §§ 1601-1693 (1994) (requiring the disclosure of standardized finance terms in credit transactions or offers to extend credit); Interstate Land Sales Full Disclosure Act, 15 U.S.C. §§ 1701-1720 (1994) (mandating the disclosure of certain information to purchasers of land in interstate transactions).

78 In other areas of health care, the government monitors the delivery of information. For example, the government, through the Food and Drug Administration, monitors the accuracy of claims made with respect to drugs and medical devices. See 21 U.S.C. § 352 (1994).

79 See Hibbard et al., supra note 60, at 405, 408,410.

80 See Jewett & Hibbard, supra note 62, at 91.

81 In the somewhat analogous context of ex ante decision making regarding advance directives, see supra note 60, tools to help patients think about future medical decisions have been developed. See Wolf et al., supra note 60, at 1668. These tools provide valuable general information on how to assist individuals in thinking about health values.

82 Albert Hirschman coined the terms “voice option” and “exit option” several decades ago. See Albert Hirschman, Exit, Voice, and Loyalty: Responses to Declines in Firms, Organizations, and States 4 (1970). More recently, Ezekiel and Linda Emanuel have argued that although the voice model views health care as a community good, the exit model views it as a market good. See Emanuel & Emanuel, supra note 57, at 147.

83 Cf. Suzanna Sherry, Responsible Republicanism: Educating for Citizenship, 62 U. Chi. L. Rev. 131, 202 (1995) (arguing, in the context of school choice, that the very act of choosing a school could be educational). Of course, because of advanced age or other considerations, some individuals may prefer not to play an active role in determining their health care priorities ex ante. These individuals could choose among various default options: one obvious-default option would be the allocation scheme chosen by the largest number of individuals.

84 See Frances H. Miller, Health Care Information and Informed Consent: Computers and the Doctor-Patient Relationship, 31 Ind. L. Rev. 1019, 1021 (1998). In response to this explosive growth of information, much of it intended for direct consumption by patients and potential patients, there has been much discussion about mechanisms for rating the quality of Internet health care information. See Alejandro R. Jadad & Anna Gagliardi, Rating Health Care Information on the Internet: Navigating to Knowledge or to Babel?, 279 Jama 611, 611 (1998) (identifying ratings of health care information on the Internet and evaluating their rating criteria).

85 See Miller, supra note 84, at 1021 n.19.

86 See Medicare Health Plans (visited May 26, 1999) <http://www.medicare.gov/managedcare.html>.

87 See Health Care Financing Administration, Health Care Financing Administration's Medicare Compare Homepage (visited May 26, 1999) <http://www.medicare.gov/comparison>.

88 See id.

89 See id.

90 See National Committee for Quality Assurance, Consumer Brochure Page (visited May 26, 1999) <http://www.ncqa.org/pages/communications/publications/98bro.htm>. With respect to any particular plan, this procedure encourages consumers: (1) to investigate quality by determining whether the plan has been accredited by the National Committed for Quality Assurance (NCQA), by determining whether it reports Health Plan Employer Data and Information Set data, and by comparing it with other plans in terms of report cards and other consumer ratings; (2) to evaluate their own needs and priorities by looking at whether their doctor is in the plan's network, whether the plan covers conditions and therapies that are important to the consumer; and at plan cost; (3) to investigate whether the plan uses financial incentives to encourage physicians to limit care; and (4) to combine the results of steps 1, 2 and 3 to make a final decision.

91 See National Committee for Quality Assurance, Accreditation Status (visited May 26, 1999) <http://www.ncqa.org/apps/searchablesl/main.asp>.

92 See Pacific Business Group on Health, Consumer HealthScope (visited May 26, 1999) <http://www.healthscope.org>.

93 See supra notes 74-75 and accompanying text.

94 See Pacific Business Group on Health, Health Plan Customer Satisfaction—Overall Satisfaction (visited May 26, 1999) <http://www.heaIthscope.org/hp/cust_sat/overall.htm>. For those who want more information, the site also presents consumer evaluations of such variables as ease of getting care, ease of getting a referral and physician interaction. See id. at Health Plan Customer Satisfaction Report Card—Index (visited May 26, 1999) <http://www.healthscope.org/hp/cust_sat/index.htm>.

95 See id. at Health Plans Preventive Care Report Card—Index (visited May 26, 1999) <http://www.healthscope.org/hp/prevent/index.htm>.

96 Id.

97 Id.

98 See id. at Physician Groups Rate the HMOs—Quality of Care (visited May 26, 1999) <http://www.healthscope.org/hp/phys_rate/qual_care.htm>.

99 See 1998 New Jersey Managed Care Plans, Compare Your Choices (visited May 26, 1999) <http://www.state.nj.us/health/hmo98>.

100 See id. at Report Contents (visited May 26, 1999) <http://www.state.nj.us/health/hmo98/contents.htm>.

101 See id. at Choosing the Right Health Plan (visited May 26, 1999) <http://www.state.nj.us/health/hmo98/choosing.htm>.

102 See id. at How HMOs and POS Plans Work (visited May 26, 1999) <http://www.state.nj.us/health/hmo98/how.htm>.

103 See id. at Access and Service (visited May 26, 1999) <http://www.state.nj.us/health/hmo98/access.htm>.

104 See id. at Qualified Providers (visited May 26, 1999) <http://www.state.nj.us/health/hmo98/qualified.htm>.

105 Id.

106 See id. at Staying Healthy (visited May 26, 1999) <http://www.state.nj.us/health/hmo98/healthy9.htm>.

107 See id. at Getting Better/Living with Illness (visited May 26, 1999) <http://www.state.nj.us/health/hmo98/getting13.htm>.

108 See id. at Care for Kids (visited May 26, 1999) <http://www.state.nj.us/health/hmo98/kidsl6.htm>. In contrast, the presentation of health plan quality information on Maryland's Internet site is more confusing. See Comparing the Quality of Maryland HMOs: Index (visited May 26, 1999) <http://www.hcacc.state.md.us/hmo/98hmo/consumer>. Maryland evaluates health plans in a variety of different categories, but does not give global ratings similar to New Jersey. See id. Instead, Maryland breaks down each main category, such as Access and Service, Staying Healthy and Getting Better/Living with Illness, into several subcategories. See id.

109 See, e.g., Kaiser Permanente (visited May 26, 1999) <http://www.kaiserpermanente.org>; Prudential HealthCare Home Page (visited May 26, 1999) <http://www.prudential.com/healthcare>; Boston Medical Center Internet Web Site (visited May 26, 1999) <http://www.bmc.org>.

110 See Pacificare Health Systems, Pacificare of California (visited May 26, 1999) <http://www.pacificare.com/california>.

111 See id. at Quality Index (visited May 26, 1999) <http://www.pacificare.com/california/members/qindex/qindex.pdf>. The underlying data for the measures are derived from claims and encounter data that provider groups and hospitals submit to Pacificare. The measures on which Pacificare focuses are preventive measures (e.g., cervical cancer screening); service measures (e.g., access-related complaints, disenrollments or transfer due to dissatisfaction with a physician or provider group); and administrative measures (e.g., submission of data regarding visits to a physician provider or hospital).

112 See id.

113 See supra notes 16-20 and accompanying text.

114 See supra notes 87-89 and accompanying text.

115 Possible comparative need allocation schemes could include the likelihood of saving life, the likelihood of saving the largest number of years of life and the likelihood of saving the largest number ofQALYs.

116 See supra notes 21-36 and accompanying text.

117 See supra note 42 and accompanying text.

118 For discussion of the NCQA reports, see supra notes 90-91 and accompanying text.

119 See supra note 80 and accompanying text.

120 See, e.g., Blumenthal, David, The Future of Quality Measurement and Management in a Transforming Health Care System, 278 Jama 1622 (1997)CrossRefGoogle Scholar (discussing the need for the health care community to utilize new information technologies, and the effect that improved information systems · will have on the decisions made by health care consumers).

121 See supra Part IV.A.

122 See supra note 8 and accompanying text.