retrievable from the MIS (e.g., registration and demographic data on members and authorized specialty referrals), but integration of the data may be cumbersome, not especially timely, and expensive. The MIS may be developed internally or be commercial with major modification by software vendors. As a result, the definitions of basic terms, coding, and recording systems are idiosyncratic and vary widely from one HMO to another.

Clinical data for review of care are typically available only in the medical record and supplemented by other sources such as laboratory or pharmacy logs. The medical record system within any one HMO may have a standard format, and a unit record may be designed so that information about care in many settings (e.g., emergency room visits, hospital discharge summary, and specialty referrals) are recorded in the primary care chart. As in the FFS system, however, medical records may differ dramatically across different HMOs.

Group and staff models have the benefit of one or several practice locations in which records are gathered. Independent practice association (IPA) and network models, on the other hand, can resemble FFS practice. An IPA would find it very difficult to require participating physicians to use common data systems because physicians often participate in many different IPAs with only a small proportion of their practice enrolled in any given IPA.

Types of Problems

Because of the financial incentives for restricting access to expensive services such as specialty care or elective hospitalization, HMOs need to look carefully for underuse. The structure of financial incentives in HMOs may lead fewer people to be nonusers, but it may also reduce services among users. HMOs are also especially prone to “procedural” barriers to access (e.g., lengthy queues for appointments) and to barriers to physician-initiated or authorized services where “gatekeeper” physicians are at financial risk for patient use of these services. HMOs tend not to have incentives that favor overuse in general or procedures over cognitive services, but they can nevertheless be subject to problems of overuse of services. Problems of poor technical care must be sought as vigorously as in FFS system.

OTHER SETTING AND SYSTEM FACTORS

We emphasized in Chapter 1 that our definition of quality of care—and by extension, the quality assurance system that should be designed to reflect that definition—was intended to include both individuals and popula-



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