February 28, 1996

Benefit LanguageCriteria That Will Improve Quality While Reducing Costs

Author Affiliations

Kaiser Permanente Southern California Pasadena, Calif

JAMA. 1996;275(8):650-657. doi:10.1001/jama.1996.03530320074047

WHETHER health system reform occurs at the national, state, or local level, one of the few things everyone can agree on is that costs must be controlled but quality must not suffer. These seemingly incompatible objectives can be accomplished, but doing that will require making controversial decisions about the use of health interventions—discouraging the use of interventions that provide little or no value and encouraging the use of interventions that have high value.1 An essential step in executing this strategy is to ensure that the benefit language by which health plans determine which interventions will be covered not only supports but encourages these types of decisions. (I will use the word "plan" to include any entity that finances the care of a population, such as government programs, indemnity insurers, and health maintenance organizations. The people covered by a plan will be called its "members.") Coincidentally, in the last few