ABSTRACT
Stimulated by Robert Kaplan's contribution, let's take a closer look at some of the technical issues involved in defining necessary care using clinical guidelines. All agree that three basic elements must be considered in developing clinical guidelines: evidence concerning health outcomes, preferences for outcomes, and service costs. Kaplan is clearly correct in saying that more sophisticated methods for estimating health outcomes and preferences are needed in the future. Of particular relevance is the question of how public values and preferences might someday be elicited and factored into the process of defining medical necessity and consequent definition basic benefit plans. This issue warrants careful consideration here. The health outcomes associated with medical and surgical services are simply the changes, or lack thereof, in patients' life-expectancy and/or health-related quality of life realized as a result of receiving those services.
