When a company decides to choose a new health maintenance organization for its employees, it’s rarely just a matter of comparing the various offerings and picking one.

Rather, it can be an intricate process involving the hiring of health insurance brokers and consultants; playing two or more HMOs off each other to get the best price; and deciding if, in the end, it’s worth switching plans at all.

While many factors lead companies to switch from one health care plan to another such as patients’ access to specialists and whether alternative treatments, such as chiropractic or herbal treatments, are offered most HMO switches are a result of just one factor: money.

“The No. 1 issue tends to be changes in cost,” said John Edelston, president of HealthPro Associates Inc., a Woodland Hills-based health care consulting firm. “So if a premium goes up by 5 or 10 or 15 percent (in a year), that tends to be a No. 1 consideration.”

What happens when an employer considers switching health plans often depends on the company’s size. Smaller companies those with a few hundred employees or less typically turn to a broker or agent. That outside expert will get details about the pre-existing health plan, including the number of employees covered and what benefits are offered, and then approach competing HMOs to see if any can offer comparable or better coverage for a lower price.

Larger companies those with big human resources departments may do more of the work internally, such as contacting individual HMOs. Even those businesses, though, typically use health care consultants to help them compare HMOs and benefits packages.

“I can’t think of a larger group that doesn’t have a consultant, and that wasn’t true 15 years ago when I started doing this in California,” said Paul Strain, director of Southern California sales and marketing for Maxicare Health Plans. Strain said companies typically use health care consultants to make sure they’re getting their money’s worth.

Once a set of bids is submitted by competing HMOs, the employer’s consultant or broker will assess the impact of switching from its current plan to a lower-cost one. The biggest impact, typically, is in the area of primary care physicians the doctors who are regularly visited by the employer’s workers.

A broker or consultant will compare the list of primary care physicians the workers already use to the list of physicians available under the new plan. If too many employees would have to switch their primary care physicians under the new, less-expensive plan, that might lessen the desire to change.

“Cost is the No. 1 concern, and the disruption in changing is No. 2,” said John Garner, president of Pasadena-based Garner Consulting, a health care consulting firm. If, under a new plan, too many employees would be forced to switch their regular doctors, the company might elect to either pay for the higher premiums of its existing plan out of its own pocket or pass the cost increase on to its employees.

Garner said consolidation of the health care industry including last year’s merger of Foundation Health Corp. and Health Systems International, and Blue Shield of California’s purchase of CareAmerica Health Plans has reduced competition, lessening the ability of businesses to strike a better deal by playing HMOs off each other.

Now, Garner said, it is usually only the larger employers that are able to negotiate lower costs or increased services in exchange for keeping them as clients. Smaller companies, by and large, do not have the same opportunity, he said.

“(Small employers) are basically purchasing off-the-shelf products, and there’s not much involved with the process,” Garner said. “It’s basically take it or leave it.”

Although most companies are primarily concerned about price when choosing a health plan, some companies also are paying more attention to the quality of care provided by various HMOs. In particular, he said, some companies are looking at the performance record of the HMOs as a way to gauge whether employees can be treated quickly and effectively. That way, productivity holds up.

“I think it’s the most enlightened companies that are doing it,” Garner said. “But I think others are following, because that approach makes sense.”