Use of cost data, provider experience, and clinical guidelines in the transition to managed care.

Since the 1920s health insurance has been based on the principle of controlling the risk pool with specific benefit limitations used to manage costs. Due to changes in the risk pool demographics, the increase in volume and intensity of services and the array of new technologies to subscribers, additional measures are needed. This trend, called "managed care," places an emphasis on clinical criteria or guidelines to regulate the utilization of subscriber benefits.1,2~3 From a reimbursement perspective, clinical guidelines should define reference points in terms of the three benefit concepts: benefit limitation, risk-benefit, and cost-benefit.