Employers, alone or in coalitions, have implemented their own pay-for-performance plans that provide bonus payments to physicians and hospitals, presumably because they believe that quality and cost-effectiveness improvements in employee care are in the employers' best interests. For outpatient activities, the most prominent employer program is the “Bridges to Excellence” program, a 3-component national ambulatory quality improvement program with a focus on diabetes, cardiac care, and physician office management (21). Physicians who demonstrate that they provide high-quality care for patients with diabetes, as measured by the criteria of the National Committee on Quality Assurance and American Diabetes Association, can receive $80 per year per patient in bonus payments. The most prominent inpatient employer-sponsored program is the Leapfrog Group, an innovative coalition of employers committed to improving quality of care (22 - 23). In Leapfrog's initial efforts implemented by health plans, purchasers, or coalitions in many areas across the United States, employers provided hospitals with additional payments for implementing the infrastructure for improving quality, such as computerized physician order entry and staffing intensive care units with board-certified intensivists.