Group Health Cooperative of Puget Sound

Health maintenance organization (HM0) information requirements are becoming more complex even though information requirements and systems are applicable to emerging delivery systems. HMO administrative data needs may be classified as: 1. planning, 2. assessing risk and designing and pricing products, 3. securing the delivery system, 4. managing plan performance, and 5. assuring quality of care and customer satisfaction. The focus of planning activities within HMOs is shifting toward program-based planning, which emphasizes the continuity and outcome of health across all providers and services. HMO data systems must effectively link exposure data with claim and cost data for predefined underwriting categories. Such data include rating category, number of dependents, and corresponding data on income, group, industrial classification, and geographic area matched with exposure period. Data systems must produce information to support distribution of incoming premiums to capitated provider categories. Administrators and directors must manage plan performance in such areas as membership objectives, financial performance, and quality of care.