BOOKS OF RtfiDIfGS - PAHO/WHO

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seem worth exploring. However, I c-in also see increasing difficulty in the future in
valuing direct tangible benefits, if fewer market prices become available for health services
'n the event that provider reimbursernent shifts away from fee-for-service toward
capitation and salay methods.
Autonmted Multhipic Screening
Often cited and discussed as an example of technologic development in the health fleld
is autonmated multiphaasic health screening (98). The reports issued from the Kaiser-
Permanente laboratories in Oakland and San Francisco reveal a good deal about the
organization and staffing of such a service and present data on unit costs (99-103). No
evaluation akin to cost-benefi¡ or cost-effectiveness analysis was attempted prior to 1973,
when a preliminary cost-benefit analysis for middle-aged men was issued (104).
Collen and associates(101) report that total costs for screening an individual are
$21.32; which, they note, is only one-fourth or one-fifth of the cost of a periodic health
examination employing more conventional modalities. The position of the authors is that
this comparison will serve for the time being, pending determination of the efficacy of
multiphasic health screening. The fact is that some people do.undergo a periodic health
examination, whatever its efficacy may be.
Garfield's position (105, 106) differs from that of Collen, in that the effectiveness of
screening in arresting or curing prevíously unknown disease is beside the point. For
Garfield, automated multiphasic screening has assumed a useful social function, serving as
a sorting mechanism tor patlents witlh ,,epayment who would otherwise flood the health
services system.
I have difficulty with both positions. Collen's comparison of cost with that of the
periodic health examination reminds one that the latter procedure is notoriously
controversial, with the central issue revolving precisely about its effectiveness. Among
physicians there appear to be true believers, persistent skeptics, and ambivalent
prescribers (107-109). Furthermore, as emphastzed in the Nuffield report (110), screening
implies an invitation to the patient to come and see the doctor who pronmises him a
'favorable outcome. This is in contrast to the more usual visit initiated by the patient who
has symptoms and seeks relief.
My criticismns of Garfield's position are more serious, for his view that automated
multiphasic screening shouJd be regarded as a sorting mechanism, a substitute for the
rationing of services by pricc, raises a host of questions. Apparently, judging from a more
recent presentation of his pGsition (1 1), much of Garfield's argument is based on an
interpretation of what happened under Medicare and Medicaid. To my knowledge, the
Medicare program experienced only a modest increase in the use of services and a huge,
unexpected, increase in unit cost. There is no way to interpret the unanticipated rise in
expenditures under Medicaid in the absence of data on trends in size of the eligible
population, per capita use, and unit cost. My own view is that the increase in eligible
population may have been the major factor.'
Garfield (111) has hypothesized a difference in price elasticity of demand between the
sick and his other three categories of patient-the well, the worried well, and the early
sick. However, there have been no empirical studies of the demand for physician servica
i See Klanan, H. E. Ma~j public initiative in health care. PubUc Intret 34: 106-123, 1974.