See

paseo
-

a

AUTOMATED MULTIPHASIC HEALTH TESTING
AND THE

REGIONAL MEDICAL PROGRAMS

*

" A Report of a Subcommittee

of the

NATIONAL ADVISORY COUNCIL ON REGIONAL MEDICAL PROGRAMS

May 11, 1971
bat

Rockville, Maryland
May 11, 1971

To: THE NATIONAL ADVISORY COUNCIL ON ”
REGIONAL MEDICAL PROGRAMS ©

In November, 1970, Council requested a subcommittee examination of automated

_.-multiphasic health testing as a regional medical program activity.

The subcommittee that received this assignment is submitting its report and
recommendations. .

The projects that regional medical programs have funded have not operated long
enough to accumulate experience that can be evaluated fairly. Summaries of
their direct cost funding and their statements of purpose and ‘benefit are
included in the report.

Most of the RMP funded projects emphasize early detection of disease and
preventive medicine as a principal reason for their existence. Health
education and conservation of physician time are also stressed as purposes of

these projects. .

With these arguments in mind, the subcommittee conducted a conference on
multiphasic health testing in Bloomfield Hills, Michigan on April 29-30.

At the conference the subcommittee heard expert presentations on the states of
the arts of: diagnostic testing; secondary prevention of chronic disease;
utilization of technicians and automation in testing program; and practical
experience with the acquisition and application of personal health data in a
variety of episodic and preventive care programs.

The subcommittee has concluded that regional medical programs should withhold
funding from any new multiphasic health testing projects, including those that
have been approved, but were not funded by the end of 1970. The subcommittee

is convinced that intensive efforts should be made to gather and evaluate the
experience that will be gained in the projects already funded. The subcommittee
also believes that modelling the natural histories of chronic diseases through
systems analysis techniques should be explored. Such explorations might identify
diseases for which preventive care of predictable value can be designed and
identify the gaps in our knowledge of others.

 

Michael J. Brennan, M.D., Chairman

 

John E. Kralewski, Ph.D.

 

Alexander M. MePhedran, M.D.

 

Clark H. Millikan, M.D.
- AUTOMATED MULTIPHASIC HEALTH TESTING
AND THE

REGIONAL MEDICAL PROGRAMS

Multiphasic health testing, as examined by the subcommittee, is the
application to a defined population of a uniform battery of tests capable
of. detecting disease or high risk of disease in persons in whom these
conditions have not been recognized. Some multiphasic health testing systems
employ several batteries of tests and measurements, each of which is applied
uniformly to a segment of the test population that is distinguished by
specified demographic, medical history, or other characteristics. Multiphasic
health testing may or may not employ automated or computer-assisted means of
acquiring medical histories, obtaining measurements and storing and retrieving
information.
Automated Multiphasic Health Testing

Among purists in the field, the term "automated" is reserved for those
systems in which automation is most extensive. In these systems not only
many individual operations, but the flow of examinees through the testing
establishment and much of the interpretation of the data obtained are computer-
controlled. The costs of. equipping and installing such a system can be amortized
within a reasonable length of time only by a high volume of service or a high fee
for service. In general the extent to which a health testing system is automated

is determined by the volume of service it is designed to perform,

Services Provided by Multiphasic Health Testing

Multiphasic health testing systems acquire data about examinees which are
similar in range of application to those acquired by a physician administering a health
check-up with the aid of laboratory services. The multiphasic: testing systems employ
non-physician technicians to acquire and process the data for physicians. This
relieves physicians of routine data collection and of the more mechanistic
interpretations. Hopefully, this reduces the time the physician spends with each
patient, and enables him to provide his higher levels of professional service to
more patients. |

Patients also save time in the testing process by comparison with the time
required for an individualized physician directed check-up. One trip through
the multiphasic testing process any replace separate visits to the physician's

office, a clinical laboratory and an x-ray department.
2

Both physicians and patients have recognized those benefits accruing from
the consistent structuring of the multiphasic testing and reporting. Automated
systems are credited with additional benefits in improved reliability. It is
claimed that automated test performance, data recording and reporting are less
error prone than similar operations controlled by humans.

The uniformity of terminology and format of a multiphasic system's reports
offer another time saving advantage. Any physician familiar with the system

can utilize any of its reports, whether he is at the initial point of referral

or comes into the case later.

In-System Economic Considerations

 

Multiphasic health testing systems may be classified as either integrated, or
free-standing. For purposes of this report, integrated systems are those that
serve fixed groups of physicians and their patients. The physicians may be in
solo practice associated with a specified hospital or hospitals or clinic on
a conventional fee for service basis, or they may be members of one or more
groups providing health and medical care under 4 prepayment plan. Integrated
testing systems are owned, under exclusive contract to, or otherwise controlled
by, the medical care groups they serve.

Free-standing testing systems accept examinees on self-referral, physician
referral or under contractual arrangements with labor, employer, or other

organizations. Their services are rendered caveat emptor, and the physicians or

patients they serve can exercise only indirect controls on their operations through

economic action.

All multiphasic systems inevitably face economic problems. In addition integrated

and free-standing systems each have special economic problems.

The Volume-Capacity Equation
A crucially important determinant of the survival of a multiphasic testing

system is the unit cost of its service. In each testing system's environment,

there is a maximum cost which cannot be exceeded for long, and there is a minimum

cost below which the service cannot be provided. The limits of this range will be
more sharply marked for free-standing than for integrated systems, but both must

accommodate to very real limits. The relationship between the volume of service

performed and the intended design capacity plays an important role in determining

the unit cost of the service. The cost of maintaining the system in readiness
tends to be close to the cost of operating at full capacity. When the volume

of service falls significantly below capacity, the cost of each unit of service
tends to mount above that contemplated in the design, When demand for services
exceeds the capacity of the system, cxcessive requests must be denied or back

logged, or extraordinatry operations must be undertaken. A decline in volume

may be more readily tolerated in an integrated system, where health care demand

and efficiencies generated by the testing may justify some subsidy of its operations.
Demand in excess of capacity may be attractive to the free-standing testing system
which may even gain. prestige by developing a waiting list. In the interest of
production neither type of testing system can long tolerate a wide disparity

between design capacity and actual volume of service,

Patient Satisfaction

Another economic constraint is imposed on the unit costs of both types
of systems by the need to satisfy the examinees. In any multiphasic testing
system it is necessary to process a large number of patients whose tests will
yield negative or normal reports. If the testing program is beneficial to the
individual, the examinee. should continue to utilize it pericdically, because
his condition may be expected eventually to change.

Continued participation of the "normal" examinee is important to the health
of the system also, to maintain its volume of service at or near design capacity.
The examinee's interest in periodic testing is directly dependent upon his
perception of the benefits of the exercise in comparison with his out lay of time
and money. Thus, a health testing system that is dependent upon periodic examination
of the same population is constrained to control its changes and to utilize the

opportunities provided by the system for health education of the examinee.

Health Care Demand in the Integrated Testing System

One of the purposes of multiphasic testing in the integrated system is
generation of increased demand for the diagnosis and treatment of pre-symptomatic,
early, or previously unrecognized chronic ‘disease. Early treatment of such disease
is alleged to improve the chance of restoring heaith and to reduce the lifetime
health care needs of the patient, if not by curing his condition at least by

reducing his needs for more costly forms of care.

To realize the benefits visualized by this hypothesis, the patient must
actively seek and persist in the indicated treatment or management of his
disease. Equally important to successful- realization of the hypothesis is the

capacity of the system to provide the indicated treatment and long term management.
The benefits of trading participation in low cost ambulatory care for
future high cost late-stage care accrue to patients who persist in, and
receive effective early stage cere. To achieve this benefit for its patients
therefore, the integrated care system must respond to the early treatment
needs it discloses with services that are effective both in contral of disease
and in retention of the patient's cooperation.

In the early years when screening is applied to a closed population, the
ambulatory care workload may increase rapidly, while the saving in more costly
forms of care is not realized. In a closed population limited capacity system,
the revelation of additional patient needs tends to frustrate their fulfillment,
because it overloads treatment resources. The medical care services are pressed
to expand and increase in cost, while cost control pressures tend to reduce the
long term gains for patients who stay in the system, to reduce patient satisfaction,
and stimulate patient defection.

In this kind of situation the system is pressed economically toward:
(a) abandonment or rigid control of its response to the preventive care indications
of its multiphasic screenings, and (b) toward dilution of the i1l and high risk
components of its patient population by acquiring new low-risk persons or by
reducing its accessibility to high risk persons.

‘The integrated multiphasic testing service that provides pre-admission or
routine work-up services for the staff of a hospital or clinic is less affected
by these economic pressures. Its services generally are performed as adjuncts
to care of acute disease and the attending physicians are not barred from
active participation in the promotion and implementation of preventive care
programs.

The free standing health testing svstem may be almost entirely free of these
pressures. Both types of testing systems can prosper at relatively constant

levels of operation as long as their services fulfill their limited promises.

Intrinsic Values of Multiphasic Health Testing
All of the foregoing economic and functional views of multiphasic health

testing have been stated without reference to the intrinsic health care values

of testing.
c

e oe
In the long run the individual examinee or patient pays the dollar costs
of the testing by dvawing either in one way or another on his personal resources,
or by drawing on protection offered to him by government. The patient also
invests time and emotion in the testing. The patient may receive three kinds

of return on his investments.

“Returns in Emotional Reassurance

The processes of obtaining professional health care are costly in money,
time and emotion.- Any increase in any of these types of expenditures will be
resisted unless it is associated with perception of offsetting reductions in

the others.

To most patients, multiphasic health testing initially offers appreciable

© emotional reassurance. Its promise of early detection and preventive care
seems both effective and up to date, It's lists of facts about the patient
assure him that his physicians will not overlook and he himself will not forget
to mention important features of his health ee The pitch of the whole
activity encourages 4 hopeful attitude toward his health.
For all patients and particularly for those inclined to pre-occupation with
health, (the weyried well) these potential returns are fragile. They are subject
to abrupt reversal by insensitive behavior of medical care personnel and by

errors or breakdowns in the testing, reporting, and medical care responses of

the system.

Returns in Process Efficiency .

Almost all multiphasic health testing systems, whether designed primarily to

© facilitate preventive care to control disease, or to assist in work-ups of acute
illness are wholly or partially additions to the patient's health care costs.
To be justified, these new expenditures should yield new benefits.

If multiphasie testing of patients with acute complaints reduces hospitalization
costs, or time spent in visits to laboratories, or shortens the diagnostic process
in almost any way, the economic return on the investment can be made obvious by
a few words from the attending’ physician. |

Multiphasic testing for preventive care and disease control is less obviously
profitable. The ultimate economic return, if any accrues, is so long in coming
@ that the patient is constrained to rely upon his convictions to justify his

expenditures.
In the detached view, the possibility of long term gain is very fragile
because it depends upon edequate performance of multiple, small, complexly related
acts over a long period of time.

Proof of ultimate gain in life cost for medical services through preventive
care is also apt to be elusive for most chronic diseases. Partly because the
prevention or containment processes applicable to much of chronic disease are
so lengthy and subject to so many kinds of lapses and ruptures, evidence that
reductions in their lifetime costs in time or money are actually feasible
will be difficult to develop. It follows that evaluation of AMHT as a factor

in preventive medicine is a long and complex task.

Returns in Health Improvement

Actual gains in longevity or even in health status resulting from multiphasic
health testing are very difficult to measure for any chronic diseases.

Much of this difficulty is rooted in lack of controls and in the lack of
knowledge of the natural histories of the diseases themselves. For some diseases
we do not know how many or which of the cases detected or forcast would not progress

to impair, function, or threaten life, even if left undisturbed, For others it is
as yet impossible to predict the effectiveness of available control measures.
For others the risks associated with available treatment have not been fully
evaluated.

Similarly, many of the parameters utilized in multiphasic health tésting are
not completely understood. This increases the difficulty of measuring effectiveness

of disease control, because it casts doubt upon the validity of the initial
detection.
Clearly an investment in multiphasic health testing as a predictable way

to obtain long-term health status maintenance or improvement remains. highly

speculative.

Current Status of Multiphasic Health Testing in-Regional Medical Programs

Ten Regional Medical Programs have invested in twelve projects that feature
multiphasic health testing that is automated to’ some degree. The regions represent —
the east and west coasts, and southeastern, midwestern and mountain states. The
populations to be served represent inner city ghetto residents, rural disadvantaged

groups, employee groups and cross-sections of hospital admissions.
-7~
|
One of the projects is primarily developmental in nature. Among the others,
the immediate objectives most frequently mentioned (See Tables 2 and 3) are
education of the examinees and of physicians and the axiomatic preventive services
of screening and casefinding. The broader purposes cited include demonstration
of the AMHT clinical approach, introduction to medical care of inadequately served
groups and modelling of improved dollar, manpower and medical efficiency for
the health service system. We have little information on plans for continuation
of these projects after their grant periods. (Table 4)
Some of the projects sponsor single examining establishments. Some
have or plan to open several. One is concentrating on mobile service in a
medically disadvantaged area and one concentrates on disadvantaged school children.
Each project has some degree of automation, and each has its own plan of tests
and measurements. Apparently none of these projects plan automation as
extensive as that developed by Kaiser Permanents, the leader in this field.
At this time we have little experience by which to evaluate these projects. Six
of the twelve projects received their initial awards in 1970, two in 1969, two
in 1968 and the developmental project began in 1967. It has taken these screening
projects from nine months to two years after their initial awards to attain |
operational status resembling that visualized in their initial plans. In the more
complex systems, de-bugging of the mechanisn, building up the volume of business,
and activating follow-up of examinees take more time.
Most of the projects have declared the intent to study themselves. Patient
and physician acceptance of the system, follow-up of examinees with abnormal
tests, system efficiency and cost-benefit comparisons are included in the plans,
as are the significance of the tests and various epidemiological topics,

Unfortunately, the studies planned to date will be of an internal nature...

The sponsors do not appear to have the base-line data and control capabilities

that would enable them to compare their AMHT systems with alternative systems

for achieving the disired purposes. Even under the best of circumstances, it
will be difficult to get highly reliable system comparisons within the relatively
brief span of a three to five year RMP grant. current study plans of the project
no not include evaluation of their effects on regionalization of health care

‘

services. .
The cumulative total of RMP investment through 1970 (See Table I) for the
direct costs of these projects was about $5,920,000, The average direct cost
avard for a project year has been about $269,000, These sums, with their
attendant overhead costs, make up a significant sharé of the total amounts of risk
money available to all regional medical programs, or to any one regional medical
program. The 1970 total for direct costs of $2,884,500 alone is 6.7% of the
$43,246,000 amount awarded for project grants in that year,

‘For this reason as well as because of the lack of consensus on so many of
the AMHT hypotheses, the questions before the council remain insistent.

Is it a concern of the RMP system to make the definitive evaluations of
the AMHT hypotheses?

Can the Regional Medical Programs (or any other single sub-system of the
medical economy) complete these evaluations in time and with sufficient authority .
to steer the nation's (or a region's) application of the valid hypotheses?

Will the hypotheses be tested in the open market, regardless of regional
medical program intervention?.

To this sub-committee it is clear that automated multiphasic health testing
is a mode of obtaining patient health data that is being tested in many of the
applications for which such data are required. Disregarding the many lively
questions that present themselves about the validity of the tests employed and
of the purposes to which the data are applied, automated multiphasic health
testing can be an efficient method of acquiring and processing the data,

Three conditions must exist in any situation in which these systems are to
become efficient. First, there must be a sufficient volume of testing to keep
the cost of operating the system commensurate with the efficiencies achieved.

Second, the automated multiphasic. testing system must be linked with
equally efficient systems for feeding examinees into the testing process and
following through on its data output, to accomplish the purposes for which the
data are acquired. The testing system is not an end in itself, unless its sole
objective is acquisition of epidemiologic information, which is a question of

questionable relevance to the RMP mission.
~Ge-

rhirdly, automated health testing as such is a method that should be chosen
only when the choice is supported by thorough cost-benefit comparisons with
alternative methods of data acquisition and processing. Because of the large
investment involved an automated testing system in an eccnomically marginal
situation can become a monster, whose needs can distort the health care system
it is intended to serve.

The sub-committee has not found evidence that AMHT itself has directly
improved regional deployment or utilization of health service resources. Some
of the purposes served by AMHT methods may have such effects but AMHT in itself
can only contribute efficiencies or inefficiencies to the performance of the
tasks assigned to it.

The sub-committee believes that regional medical programs should concentrate
on improving deployment and utilization of practice-ready health care systems of
predictable effects. So many of the hypotheses on-which AMHT rests are unproven
that it cannot be credited with predictability as positive influence in health
care-

The sub-committee also finds that the uncertainties surrounding preventive
health care are not likely to be resolvable within the life span of a regional
medical program project.

Recommendations of the Subcommittee
The. subcommittee proposes that the Council issue the following recommendation:

VAC this time eleven regional medical programs have funded projects that
feature automated multiphasic health testing. The purposes of these
projects present a-fair representation of the purposes for which patient
health status data are acquired.

"Automated health testing is very costly. The influence of the projects
in which it appears on regional deployment and utilization of health
care services is highly unpredictable, For these reasons Council recommends
that no new projects featuring automated health testing be funded.

"The Council further recommends that the Director, RMPS, and the appropriate
regional medical programs, coordinating with the National Center for Health
Services Research and Development, Community Health Services, the National
Center for Health Statistics, the National Institute of General Medical
Seiences and other interested agencies, institute consultation and

investigation to:
 

Provide market and financial anaivses and advice to avoid lass in post-
grant operations of projects currently funded by regional medical programs:
Build into RMP and other projects base line’ data, defined goals and measures
of progress for cohorts of persons whose initial multiphasic tests were
positive, negative and refused, among such populations as urban and

rural poor, employee groups, hospital and clinic patients, to help resolve
debate about the affects of multiphasic testing on quality of and access

to health care services and the regional deployment and utilization of
health care resources; and

Utilize systems analysis and all available epidemiologic information to

Atart.

stimulate natu al histories of diseases and identify those for which

M

secondary prevention might be feasible and acceptable in cost."
AUTOMATED MULTIPHASIC TESTING IN REGIONAL MEDICAL PROGRAMS

TABLE 1. DIRECT COST FUNDING, FISCAL YEARS 1967-70

 

 

 

 

 

 

 

 

Region Project Direct cost commitments (Thousands of dollars) Project
No. Name No. 1967 1968 © 1969 1970 Total Years
9 Missouri | 4R 421.5 274.3 317.5 "121.0 1134.3 4
25 Rochester, N.Y. 7 | . 202.2 ~ 265.5 259.9 727.6 3
18 “Tenn. Mid-South 28 245.5 798.8% "604.5 1648.8 - 3
24 Florida 1 202.5 179.2 381.7 2
43 Indiana 2 225.0 225.0 . 450.0 2
4b Maryland 2 83.0 76.8 159.8 2
49 Ohio Valley 7 | 200.0 200.0 1
19 California 38 . 91.0 91.0 1
19 California 46 , | 187.6 187.6 1
15 Intermountain - 26 . 358.3 358.3 1
51 Memphis. 18 | 312.6 312.6 1
5. Memphis | 17 | | 269.5 269.5 aL

TOTAL 421.5 722.0 1892.3 288475 5920.3
Project years . “4 3 6 12 22
Average funding, project year — - 421.5 240.7 315.4 240.7 269.1

*fneludes $192,000 for renovation of space.

. 4/23/71
AUTOMATED MULTIPHASIC TESTING IN REGIONAL MEDICAL PROGRAMS

TABLE 2. PURPOSES OF FUNDED PROJECTS

 

Region Project First
No. Name No. Year Stated Purposes
9 Missouri 4R 1967 Establish centers to determine diagnostic laboratory tests useful
, for screening populations.
25 Rochester, N.Y. 7 : 1968 Detection of early disease in selected population, evaluation of
, data collecting systems,

18 - Tennessee ~ Mid South 28 1968 Health evaluation studies on a defined population group, preventive

care, case-finding, bringing disadvantaged group into health care
: system. e

24 Florida 1 1969 Education (unspecified) preventive care, pre-admission evaluation,
case-finding, research,

43 Indiana 2 . 1969 Casefinding, educational (patients) preventive care, research.

44 Maryland 2 1969 Development and evaluation of screening children of low-income

, families, primarily for cardiovascular and pulmonary disease.

49 Ohio Valley : 7 1970 Automated multiphasic screening demonstration; physician
education, case-finding, pre-admission evaluation.

19 California 38 1970 Screening urban poor population using an OEO. ambulatory

, care units.
19 California 46 1970 Preventive care, bringing urban poor and migrants into health
care system, case finding, patient education.

15 Intermountain 26 1970 Preventive care, casefinding, education (patient) minor research.

51 Memphis 18 1970 Improving health service for residents of a northeastern Miss. area.

51 Memphis |. . 17 1970 Preventive care, patient education, research, improve manpower

: utilization.

sour

Primary
Character
Developmenta!

Demonstration

Demonstration

Demonstration

Demonstration

Developmental
Demonstration
Demonstration
Demonstration

Demonstration
Demonstration

Demonstration ;
4/23/71
43

44

49

19

15

Region
Name

Missouri

Rochester, N.Y.

Tenn. Mid-South

Florida

Indiana
Maryland

Ohio Valley

California

California

Intermountain

AUTOMATED MULTIPHASIC HEALTH TESTING IN REGIONAL MEDICAL PROGRAMS

Project

No.

4R

7

28

38

46

26

TABLE 3.

BENEFITS TO REGIONAL MEDICAL PROGRAMS

Benefits cited by applicants

 

AMHT systems design.

Prestige of innovating a service.
Links community and providers in demonstration.

Early detection of target diseases.
Project's visibility in community helps RMP.

Education, service coordination, research
+ ’

Helps round out medical care in community service,
education, research,

Service to disadvantaged school children
Model child screening system,

Demonstrate MHT, educated physicians in
comprehensive, preventive care and health manpower
utilization.

Not yet operational, regional strategy not cited.

Early detection of target diseases
Service to disadvantaged
Brings disadvantaged into care system.

Reduce disability and hospitalization.
Reduce overall costs of medical care.
Apply modern techniques to medical records.
Employ and train para-medical personnel.

To provide comprehensive care by integrating
with health center. .

e °

la & WN ee
.

Noted by others

Brings disadvantaged into the health
system..

Cooperation among institutions

Could bring disadvantaged population
into better care,

Brings disadvantaged population into
better care,

Improves clinic service to low income
area,

4/23/71
 

51

Region
Name

Memphis

Memphis

Project
No.

 

18

17

BENEFITS TO REGIONAL MEDICAL PROGRAMS

Benefits cited by applicants

A community generated solution to area needs.

Model preventive care clinic system.

Noted by others
18

43
44
49

19
19

15

51
51

Region
Name

Missouri

Rochester, N. Y.

Tenn. Mid-South

Florida

Tadiana
Maryland
Chio Valley

California
California
Intermountain

Memphis ©
Memphis :

AUTOMATED MULTIPHASIC HEALTH TESTING IN REGIONAL MEDICAL PROGRAMS

 

 

Equipment

PLANS FOR POST-GRANT SUPPORT OF DIRECT EXPENSE

Cost. grant plans
Operating expense

 

100% RMP - Now combined with other dev. projects

TABLE 4.
Project RMP Support Plan
No Operating expense
4R
7 100% RMP-3 years
{

28 100% RMP - 4 years
1 100% RMP, 2 years,
50% 3rd
2 100% RMP, 3 years

2
7 RMP and Hospitals
38 Not operational
46 100% RMP, 3 years
26 100% RMP, Ist year,
declining for 5 years
18
17

Operating since 1956,

$6100 Clinical

$225,000 lab. &
clin. 15,000
p.a. computer

$140,000 clinical

$33,800 lab & Clin.

Related to school health programs

Will contract for
Lab.

$968 laboratory
$140,000 computer
52,500 clinical

“

sharé assumed . by
RMP not clear

Hope for 3rd party
approval, industry
contracts.

80% revenue '
20% grants

40% patient revenues
60% VA and research
No plans given

No plans given

100% hospital revenue

Plans not yet started

$12,000 p.a. from county

No other shown.

$525,000 revenue p.a.
after 5 years

«

Revenue Pts. needed

 

Flexible

$15,000

6,200

Flexible

Flexible

20,000

lexibl
Flexible 1123/71