sures of well-child care—which constitutes a major aspect of primary health care services for children—are the number of doctor visits children received and whether or not they have been immunized or screened for previously undetected health conditions (e.g., anemia) These are arguably important and necessary measures, but clearly not sufficient to determine if children have had their developmental risks assessed in a timely or appropriate fashion, whether their behavioral and emotional problems have been recognized and dealt with, or whether they have been followed to ensure resolution or improvement of their problems. They also assess only children in participating insurance plans (Kuhlthau, Walker et al., 1998; Perrin, Kuhlthau et al., 1997; Newacheck, Stein et al., 1996). Moreover, HEDIS has no comparable data collection on those without insurance, the under-insured, or those not enrolled in a health services organization that provides data to NCQA.

There has been progress over the last several years in measuring the quality of health services provided to children and the potential effect of different kinds of health services on their health. However, such measurements are not being collected as part of routine monitoring of quality and are not being collected at all on the most deprived segments of the population. Moreover, since the data collection mechanisms (even within HEDIS) are voluntary, some health maintenance organizations have decided not to monitor the health of children. Here, as in many other instances, the efforts are directed principally at the health of adults. Moreover, they are family-based and not a community of population-based assessments and give no clues either about averages or distributions in the population.

Challenges in Measuring Services

Although the United States has relatively good statistics on overall access to and use of health services, primarily through its national surveys, the data are notably inadequate for assessing access to and use of different levels of health services (including primary care and specialty care) and the effectiveness of those services. In current data, the concept of “access” is often confused with use of services, despite the fact that access facilitates care but does not reflect services sought or provided. Health surveys usually address the issue of access to and use of “a regular source of care,” which may or may not be a primary care source. Modifications of survey questions sometimes inquire whether the source is the same for both preventive and illness care (with increased likelihood that the source is primary care if both are the same), but there is still no direct data on the extent and distribution of primary care at any geographic level in the United States or on the actual services provided.

Although some effort has been directed at improving measurement of personal health care services, far less has focused on assessing the performance of the



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